Edits and Rejections-Associates and QA

Job Title: Hospital Billing Executive Claim Edits & Rejections

• Department: Revenue Cycle Management (RCM) Hospital Billing / AR
• Location: [Insert Location / Remote]
• Reports To: Team Lead / Billing Supervisor
• Employment Type: Full-Time

Job SummaryWe are seeking a detail-oriented and experienced Hospital Billing Executive specializing in Claim Edits and Rejections. The ideal candidate will be responsible for reviewing, troubleshooting, and resolving pre-submission clearinghouse edits, system validation flags, and direct payer rejections for institutional/hospital claims (UB-04). Your goal is to maximize first-pass claim acceptance rates, prevent avoidable denials, and ensure prompt revenue realization.

Key Responsibilities

• Claim Edits & Scrubbing:
• Review and resolve automated and manual claim edits flagged by internal practice management systems or clearinghouses before transmission.
• Analyze and resolve Inclusive and Exclusive Edits (e.g., CCI/NCCI edits, component code conflicts).
• Rejection Management:
• Investigate, correct, and resubmit rejected claims from clearinghouses and insurance carriers (Medicare, Medicare Advantage, and commercial payers).
• Address Medical Necessity (MN) rejections and clinical documentation gaps associated with hospital claims.
• Data Validation & Error Correction:
• Validate and correct critical claim components, including:
• Payer ID and Invalid Member/Subscriber ID errors
• Provider NPI, taxonomy, and billing/rendering provider mismatches
• Invalid or missing ICD-10 diagnosis codes and CPT/HCPCS procedure codes
• Duplicate claim flags and demographic/DOB/gender mismatches
• Institutional Claim Processing:
• Ensure accurate formatting, revenue code mapping, and submission of UB-04 (CMS-1450) claim forms for inpatient and outpatient hospital services.
• Compliance & Guidelines:
• Stay updated on Medicare (CMS) and commercial payer billing guidelines, regulatory updates, and contract terms.
• Collaboration & Reporting:
• Coordinate with Medical Coding, Accounts Receivable (AR), Quality Assurance (QA), and IT/Clearinghouse support teams to root-cause recurring errors.
• Maintain established Key Performance Indicators (KPIs), daily productivity targets, and quality standards (e.g., First-Pass Yield and Turnaround Time/TAT).
• Experience:
• [e.g., 2 to 5+ years] of hands-on experience in US Healthcare Revenue Cycle Management, specifically focused on hospital billing, claim edits, and rejections.
• Technical Knowledge:
• Strong mastery of UB-04 billing standards, institutional claim forms, and revenue codes.
• In-depth understanding of ICD-10-CM, CPT, and HCPCS coding rules.
• Familiarity with Medicare, Medicaid, and Medicare Advantage (Part A/B/C) guidelines.
• Experience working with major clearinghouses (e.g., Change Healthcare, Availity, Waystar) and hospital billing software (e.g., Epic, Meditech, Cerner, 3M).