RCM Specialist

We are seeking an experienced RCM Specialist with expertise in Wound Care Medical Billing, Coding Support, Claims Management, and Denial Resolution . The ideal candidate should have in-depth knowledge of wound care procedures, payer guidelines, medical necessity requirements, and reimbursement processes. The specialist will be responsible for ensuring accurate claim submission, timely reimbursement, and effective denial management while maintaining compliance with payer policies and industry regulations.

Key Responsibilities

Medical Billing

• Review provider documentation for completeness and billing accuracy.
• Submit clean claims within established turnaround times.
• Verify patient demographics, insurance eligibility, and authorization requirements.
• Ensure proper linkage of ICD-10-CM, CPT, and HCPCS codes.
• Monitor claim acceptance and resolve clearinghouse rejections promptly.
• Review Explanation of Benefits (EOBs) and Electronic Remittance Advices (ERAs).
• Post payments accurately and identify underpayments or payment discrepancies.
• Follow up on unpaid and partially paid claims until final resolution.
• Maintain payer-specific billing guidelines and reimbursement updates.

Wound Care Billing Expertise

The specialist must have working knowledge of billing and documentation requirements for:

Debridement Procedures

Skin Substitute and Grafting Procedures

Advanced Wound Care Procedures

Denial Management Responsibilities

• Analyze denied claims to identify the root cause.
• Resolve coding, billing, and documentation-related denials.
• Prepare and submit first-level and second-level appeals.
• Review payer policies and LCD/NCD guidelines.
• Identify denial trends and recommend preventive actions.
• Coordinate with providers and coding teams to obtain additional documentation.
• Track appeal outcomes and maintain denial logs.
• Reduce denial rates and improve first-pass claim acceptance.
• Meet established turnaround times for denial resolution.

Accounts Receivable (AR) Follow-up

• Follow up with commercial, Medicare, Medicaid, and workers' compensation payers.
• Resolve aging claims across all AR buckets.
• Identify payment variances and recover underpayments.
• Escalate high-value accounts when necessary.
• Maintain productivity and quality standards.

Required Technical Knowledge

The candidate should demonstrate proficiency in:

• ICD-10-CM diagnosis coding
• CPT and HCPCS procedure coding
• NCCI edits
• LCD and NCD coverage policies
• Medical necessity requirements
• Modifier usage (e.g., 25, 59, X{EPSU}, JW, JZ, GA, GY, GX, KX)
• Global surgical package guidelines
• CMS billing regulations
• Medicare and commercial payer policies
• Prior authorization requirements
• Coordination of Benefits (COB)
• Appeals and reconsideration processes
• Claim correction and reopening procedures

Required Skills

• Strong analytical and problem-solving abilities.
• Excellent written and verbal communication skills.
• Attention to detail and high level of accuracy.
• Ability to manage multiple priorities in a fast-paced environment.
• Strong understanding of payer reimbursement methodologies.
• Ability to work independently and collaboratively with clinical and administrative teams.

Qualifications

• Minimum 3–5 years of experience in U.S. medical billing and Revenue Cycle Management.
• Minimum 2 years of hands-on experience in wound care billing and denial management.
• Experience billing Medicare, Medicaid, and commercial insurance plans.
• Knowledge of wound care reimbursement policies and documentation standards.
• CPC, COC, or CCS certification is preferred.
• Associate's or Bachelor's degree in a healthcare-related field is preferred.