Submission & Resubmission Officer

Job Description

• Ensure that claims (IP / OP) are coded to the highest specificity for Diagnosis using ICD-10 CM codes and relevant CPT/HCPCS codes and adjudicated as per Payer Policies.
• Ensure that the administrative details (Eligibility & authorization verification) are captured correctly in the bill to ensure claim payment in the initial submission.
• Meets the assigned daily target as per the RCM requirements – Finalize 250 OP per day or 18 IP per day. Targets may be revised based on workload, staffing, and management discretion.
• Upload e-claims to the regulator portal DHPO or RIAYATI for direct billing claims.
• Report variations or irrelevance in CPT codes used for services/procedures and communicate with the Clinicians for missing / correct documentation.
• Assist in providing proper CPT/HCPCS codes for newly added services/procedures.
• Claims Resubmission:
• Review the denied IP / OP claims and identify the Root cause analysis of denials Resubmit claims with appropriate documentation and remarks after reviewing the complete documentation in EMR.
• Meets the assigned daily target as per the RCM requirements – Process for resubmission 150 OP claims per day or 12 IP claims per day. Targets may be revised based on workload, staffing, and management discretion.
• Denial trend reporting to management - Identify the rejection trends and analyze and escalate for appropriate action
• Coordinate with Payers for clarification of denials and queries raised by the Payers.
• Work in coordination with the RCM Manager to support claims reconciliation, payer audits, and other assigned activities.