Submission & Resubmission Officer

The duties and responsibilities of the RCM Officer – Submission & Resubmission

at NMC Royal Hospital, Sharjah, are as follows:

Claims Submission:

• 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.

Training and Reporting:

• Support in Daily reporting and preparing denial and submission reports

• Support coding and compliance training and provide training materials and support to Claims processors – Submission & Resubmission and clinical team regarding ICD/CPT and other medical coding requirements.
• Provide timely feedback about rectification of the denials related to Coding, billing and approvals.

General Responsibilities

• Maintain confidentiality of patient, clinical, and insurance information.
• Adhere strictly to hospital policies, payer requirements, and regulatory guidelines.
• Accurately enter and maintain coding data in hospital billing systems.
• Be available to clinicians and internal stakeholders for ICD/CPT clarification and coding support.
• Perform any additional RCM-related tasks as assigned by the RCM Manager.

Qualification 

Bachelor's degree in nursing, pharmacy, physiotherapy, or related fields preferred. 

AAPC or AHIMA certification preferred / mandatory as per hospital policy 

Experience 

Minimum 2 years of experience in a similar role