RCM Officer

Job Summary

The RCM officer maintains patient’s details, scans documents related to patient registration personal and insurance requirements.  S/He will secure pre-approvals for all contracted payers and assist patients with insurance coverage. S/he will submit and Adjudicate approval and claims, daily within the time and with clear justification, Patient SOB, policies, procedures, and insurance guidelines, as outlined by payer contractual agreements and according to rates as reflected in respective paper contracts.

Job Responsibilities 1

Studies insurance plans used most frequently from patients to understand the various nuances to communicate more effectively.

Validates patients details in the system with the scanned and uploaded patients’ documents.

Assists Patient Access team regarding insurance requirements and co-payments/cash deductible.

Reviews in-house patients' documents details/approval/ claims and ascertains the quality of the claims as to:

Accuracy of the entries/charges,

Accuracy and completeness of approvals,

Limits properly applied,

Follows up on all pending approvals within 24 hours and responds to urgent requests in a timely manner.

Submits all new Complex authorization approvals and/or Complex re -authorization approvals through the Complex audit process.

Submits the claims with proper coding and documentation also as per the approval to avoid rejection.

Job Responsibilities 2

Abstracts all the information required to support accurate coding.

Reviews respective coding (i.e. CPT, HCPCS, ICD-10) to ensure that claims are billed in compliance with MoPH standards and corrects coding guidelines and payer standards.

Adheres to the Claims and Adjudication rules and coding guidelines of every individual insurance party and applies policies and co-payment to confirm that claims meet criteria for payment and follows contractual guidelines.

Communicates with the Registration team about the financial agreement with the patient, such as payment amount and schedule for pre-authorisation.

Contacts the physician’s office to obtain the clinical documentation and current prescriptions required by the plan and validates that they meet the requirements for approval and submission.

Handles daily all inquiries concerning insurance.

Processes and submits insurance claims daily and follows up on outstanding claims.

Sends information as requested by insurance companies such as x-rays, charting, narratives, and other documentation for processing the claim when applicable.

Additional Responsibilities 3

Job Knowledge & Skills

Proficient in all Microsoft Office applications as well as medical office software.

Proven experience in healthcare Preapproval and billing.

Sound knowledge of health insurance providers.

knowledge of Revenue Cycle Management within Billing, Approval, and Collections.

Knowledge of payer websites, processes, local, state, and federal requirements.

Aware of current trends related to medical necessity, consumables of related procedures.

Aware of denials in Claims and process of pre-approvals and submission with accurate supporting.

Knowledge of deductibles, co-payments, co-insurance amounts, insurance exclusions and other policies.

Excellent interpersonal skills.

Ability to work in a fast-paced environment.

Effective time management and organizational skills.

Job Experience

Minimum 1 year of experience in Healthcare Billing and Insurance (required).

Expertise in Pre-Approval insurance process and submission of the claim in insurance portal along with the per-approval.

Minimum 1 year of experience in GCC (required).

Competencies

Education