Senior-rcm claim-BC sector health

Job Title: Health sector senior

Domain: Revenue Cycle Management (RCM) Healthcare

Experience Required: 56 Years

Experience

• 56 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

• Bachelors 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.