Edits and Rejections-Associates and QA (Hyderabad)

Edits and Rejections-Associates and QA (Hyderabad) Company: Eclat Health Solutions Job Location: Hyderabad, Telangana, India Employment Type: Full-time Experience Required: 2 - 5 years 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 Summary We 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). .