Clinical Readmission Review Auditor III

This role focuses on evaluating the clinical circumstances surrounding related inpatient admissions, the care delivered, discharge planning, and whether the subsequent admission may have been clinically related or potentially preventable. The position is fully remote within the United States and may require up to 10% annual travel for team meetings or limited client engagements.

A brief coding/auditing assessment may be included as part of the interview process

Salary Range: $70,000 - $98,700 | Location: 100% Remote, U.S.-based | Travel: Up to 10% annually

For more information on benefits and what we offer please visit us at https://www.exlservice.com/us-careers-and-benefits

Responsibilities

• Conduct comprehensive clinical reviews of initial and subsequent inpatient admissions to evaluate the relationship between episodes of care.

• Review the complete medical record, including clinical presentation, diagnoses, treatment, response to treatment, discharge disposition, follow-up plan, and subsequent readmission.

• Assess whether the readmission was clinically related to the prior admission and whether opportunities existed to prevent or reduce the likelihood of readmission.

• Evaluate the medical necessity and clinical appropriateness of inpatient services using applicable clinical criteria, client requirements, and evidence-based standards.

• Identify concerns involving discharge readiness, continuity of care, follow-up services, medication management, or other clinical factors documented in the record.

• Prepare clear, concise, and well-supported clinical findings that accurately reflect the documentation reviewed and the rationale for the determination.

• Respond to provider disputes or appeals by completing an objective clinical reassessment and supporting the final determination with relevant medical-record evidence.

• Meet EXL quality, productivity, timeliness, and documentation standards while maintaining consistent and defensible review decisions.

• Maintain current knowledge of readmission review practices, clinical guidelines, utilization management principles, and applicable regulatory or client requirements.

• Protect confidential information and comply with HIPAA and EXL policies and procedures.

Qualifications

• Education and licensure: Active, unrestricted Registered Nurse (RN) license in the United States is required. Bachelor of Science in Nursing (BSN) is preferred.

• Clinical experience: At least four years of acute-care clinical nursing experience. Experience in inpatient case management, utilization review, clinical auditing, quality, or readmission review is preferred.

• Clinical expertise: Strong knowledge of inpatient care, disease progression, discharge planning, transitions of care, medical necessity, and factors contributing to readmissions.

• Documentation review: Ability to synthesize complex medical-record documentation and make objective, evidence-based clinical determinations.

• Communication: Strong written and verbal communication skills with the ability to explain clinical findings clearly and professionally.

• Technology: Proficiency with Microsoft Excel, Word, and OneNote, along with strong overall computer literacy.

• Work environment: Self-motivated and able to work independently in a remote setting while meeting quality and productivity expectations.

 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.