Submission & Resubmission Officer

Role Overview

Submission & Resubmission Officer at NMC Healthcare, NMC Royal Hospital, Sharjah.

Role Purpose

Ensure accurate medical coding, claims submission, resubmission, reconciliation, and compliance with Payer policies and procedures with a strong focus on insurance portal submissions, denial reduction, and revenue optimization.

Key Responsibilities

Claims Submission

• Ensure 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 administrative details (Eligibility & authorization verification) are captured correctly in the bill to ensure claim payment in the initial submission.
• Finalize 250 OP per day or 18 IP per day and meet assigned daily targets as per RCM requirements; 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 and procedures and communicate with Clinicians for missing or correct documentation.
• Assist in providing proper CPT/HCPCS codes for newly added services and procedures.

Claims Resubmission

• Review denied IP/OP claims and identify root cause analysis of denials; resubmit claims with appropriate documentation and remarks after reviewing complete documentation in EMR.
• Process for resubmission 150 OP claims per day or 12 IP claims per day and meet assigned daily targets as per RCM requirements; targets may be revised based on workload, staffing, and management discretion.
• Identify rejection trends and analyze and escalate denial trend reporting to management for appropriate action.
• Coordinate with Payers for clarification of denials and queries raised by Payers.
• Work in coordination with the RCM Manager to support claims reconciliation, payer audits, and other assigned activities.

Training and Reporting

• Support daily reporting and prepare 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 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.

Qualifications & Experience

• Bachelor's degree in nursing, pharmacy, physiotherapy, or related fields preferred.
• AAPC or AHIMA certification preferred or mandatory as per hospital policy.
• Minimum 2 years of experience in a similar role.