Senior-rcm claim-BC sector - health

Job Title: Health sector senior

Domain: Revenue Cycle Management (RCM) – Healthcare

Experience Required: 5–6 Years

Experience

• 5–6 years of experience in medical coding, claims adjudication, charge capture, and healthcare billing within provider, hospital, ASC, or DME environments.
• Demonstrated expertise in ICD 10 CM, CPT, and HCPCS Level II coding, including complex modifiers and payer-specific requirements.
• Strong hands-on experience in Clinical Documentation Excellence (CDE), physician queries, and improving provider documentation quality.
• Proven experience in medical device credit coding and billing, including DME equipment, implants, returns, warranty credits, and payer-driven credit adjustments.
• Experience supporting charge capture integrity, reconciliation, and revenue leakage analysis.
• Background handling claim rejections, denials, appeals, and root cause analysis to drive first-pass resolution and reduce A/R.
• Exposure to payer rules, NCCI edits, medical necessity guidelines, LCD/NCD compliance, prior authorization requirements, and reimbursement models.
• Experience working with cross-functional teams including providers, clinical operations, revenue integrity, and payer relations to resolve complex billing issues.
• Familiarity with EHR/PM systems such as Epic, Cerner, Athena, NextGen, Meditech, eClinicalWorks, or equivalent.

Education

• Bachelor’s degree in Healthcare Administration, Life Sciences, Nursing, or Allied Health.
• Coding certifications preferred: CPC, CCS, COC, CPB, or equivalent AAPC/AHIMA credentials.
• Training/credentials in Clinical Documentation Improvement are an advantage (CCDS, CDIP).

Preferred Background

• Experience working with RCM organizations, provider groups, hospitals, ASC centers, or DME suppliers.
• Strong understanding of charge entry workflows, charge master usage, device credit processing, and payer rules.
• Exposure to denials management, medical necessity validation, and payer communication.
• Familiarity with digital health workflows, claim scrubbing tools, edits management systems, and clearinghouses.
• Experience working with U.S. healthcare payers, Medicare/Medicaid, and commercial payer requirements.

Role Summary

The Senior Claims, Coding, Charge Capture & Billing Specialist plays a critical role in ensuring the accuracy, compliance, and timeliness of coding, charge capture, and billing processes. The role supports revenue cycle operations by analyzing documentation, reconciling charges, validating device usage, managing claims, and minimizing financial risks due to inaccuracies. This specialist ensures coding integrity, reduces denials, and supports continuous improvement across the revenue cycle.

Key Responsibilities

Coding & Documentation

• Review clinical documentation and assign compliant ICD 10 CM, CPT, HCPCS Level II codes with appropriate modifiers.
• Conduct CDE reviews, identify documentation gaps, and issue provider queries to validate medical necessity and specificity.
• Audit coding for accuracy and compliance; support internal and external audit readiness.

Charge Capture & Reconciliation

• Ensure complete and accurate capture of professional and facility charges.
• Reconcile case logs, operative notes, device usage logs, supply chain records, and CDM entries.
• Identify missing, duplicate, and incorrect charges and perform timely corrections.

Medical Device Credit Coding & Billing

• Manage device credit workflows, including returns, replacements, warranty credits, and payer-required reporting.
• Apply correct device-related HCPCS codes and modifiers, ensuring compliance with Medicare and commercial payer rules.
• Coordinate with supply chain, OR/clinical teams, vendors, and revenue integrity to validate device usage and credit memos.

Claims, Billing & Denials Management

• Prepare, correct, and re-submit claims; resolve scrubbing edits for coding, enrollment, and charge-related issues.
• Analyze denial trends and implement corrective actions to prevent recurrence.
• Develop and submit appeals with supporting medical documentation and coding justification.

Compliance & Regulatory Adherence

• Adhere to coding guidelines, payer requirements, LCD/NCD policies, NCCI edits, and RCM compliance protocols.
• Ensure HIPAA compliance and maintain audit-ready documentation.

Operational Excellence

• Track KPIs (coding accuracy, denial rate, first-pass acceptance, device credit turnaround).
• Partner with coding quality teams, auditors, and clinical departments to improve documentation and reduce revenue leakage.
• Contribute to process enhancement, workflow streamlining, and best practice sharing.

Must-Have Skills

• Strong working knowledge of ICD 10 CM, CPT, HCPCS, and medical terminology.
• Proven experience in CDE, coding audits, and advanced documentation review.
• Expertise in medical device credit processing and billing compliance.
• Strong analytical, problem-solving, and root cause analysis skills.
• Excellent communication skills to collaborate with clinical and non-clinical teams.
• Ability to navigate multiple systems and work in high-volume, accuracy-driven environments.

Nice-to-Have Skills

• Experience with digital RCM tools, automated charge capture, or coding AI systems.
• Knowledge of payer reimbursement strategies, value-based care models, or care delivery workflows.
• Familiarity with appeals, RAC audits, or compliance reviews.
• Exposure to quality measures, HEDIS, or risk adjustment models.