Skilled Nursing Facilities (SNF) Auditor III

EXL; Oregon; Hybrid; USD 60,000 - 99,000; Full time

Job summary

EXL is seeking a Skilled Nursing Facility auditor to validate billed charges, applying CMS guidelines, PDPM/RUG concepts, and HIPPS knowledge. This fully remote role conducts clinical reviews, documents audit findings, and supports opportunities to improve reimbursement integrity.

You will rely on EXL tools and industry standards, work with cross-functional teams, and maintain HIPAA compliance while delivering accuracy and timely audit determinations.

Qualifications

• Active nursing license (RN/LPN/LVN) required.
• 3+ years of skilled nursing auditing experience.
• RAC certification preferred; knowledge of PDPM/RUG.
• Experience with PDPM, RUG, Medicare reimbursement systems.
• Experience with HIPPS codes and days of billing.

Responsibilities

• Conduct clinical reviews to verify SNF billing accuracy.
• Apply CMS guidelines to identify overpayments under PDPM, RUG, and per diem.
• Apply ICD-10 coding guidelines to validate MDS diagnoses.
• Document audit results clearly using EXL tools and CMS guidelines.
• Move claims through workflow, generate audit rationales, and meet productivity goals.
• Maintain HIPAA compliance and regulatory requirements.

Skills

RN/LPN/LVN license

Skilled nursing experience

RAC certification preferred

PDPM/RUG knowledge

HIPPS billing knowledge

Strong communication & analytical

Remote work independently

Education

Associate's or Bachelor's degree in nursing

Bachelor's degree preferred

Tools

EXL proprietary tools

Excel

Job description

In this fully remote position as a Skilled Nursing Facility auditor you will apply your expert clinical knowledge to validate the accuracy of billed charges to ensure the integrity of the paid claim including coding validation, payment accuracy, contractual requirements and compliance with regulations. You will utilize industry and EXL proprietary tools in the review process, and will write professional communications documenting audit findings and supporting rationales. You will also apply your extensive clinical and industry knowledge to identify audit trends and opportunities.Salary Range: $60,100 - $98,700 (based on experience, skills, and qualifications)Location: 100% Remote (U.S.-based)Up to 10% annual travel (for team meetings and limited client onsite engagements.)A brief coding/auditing assessment may be included as part of the interview processFor more information on benefits and what we offer please visit us at

Responsibilities

• Conduct clinical reviews to verify the accuracy of skilled nursing facility billing.
• Apply CMS clinical guidelines and payer-provider contract terms and policies to a variety of claim scenarios to identify overpayments for claims paid under PDPM, RUG, and contracted per diem payment methodologies.
• Apply ICD-10 coding guidelines to validate diagnoses coded on Minimum Data Set assessment.
• Document accurate audit results in a clear, concise, and effective manner using applicable EXL tools, CMS guidelines, payer contractual terms and policies.
• Utilize proprietary workflow systems efficiently and accurately to make audit determinations, generate audit rationales and move claims through workflow process correctly.
• Meet or exceed EXL established program productivity and quality goals.
• Demonstrate knowledge of and compliance with changes and updates to clinical guidelines, reimbursement trends, and client processes and requirements.
• Comply with all EXL policies and procedures including HIPAA and other state and federal regulations.

Qualifications

Required:

• RN/LPN/LVN with current active license
• LPN, Registered Nurse with Associate's or Bachelor's degree preferred
• 3+ years of skilled nursing experience with preference given to candidates with RAC certification, reimbursement or MDS coordinator with knowledge of PDPM/RUG.
• Previous experience/exposure to RUG and PDPM Medicare reimbursement systems and the Medicaid 48 grouper reimbursement system
• Previous experience/exposure to the billing of HIPPS codes and days of billing for each assessment type.

Knowledge and Skills

• Possesses excellent time management and work prioritization skills.
• Demonstrates excellent written and verbal communication skills, strong analytical skills, and attention to detail.
• Proficient in Excel, Word, and OneNote with general computer literacy.
• Passionate about auditing skilled nursing claims with a desire to work in an environment thriving on teamwork, excellence, collaboration, inclusiveness, and support.
• Works independently in a remote environment and delivers exceptional results during EXL core business hours.
• Takes ownership of problem solving.

The posted base salary range is the hiring base salary range for this role. Final offers are based on several factors, including: the candidate's skills and experience, internal pay equity, work location, market conditions for the role, and the specific scope and responsibilities of the position.