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:
- Solid 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).

📌 Edits and Rejections-Associates and QA (Hyderabad)
🏢 ECLAT Health Solutions
📍 Hyderabad