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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.
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