Senior Process Executive - Clinical Specialist

DJO Global; Hyderabad; On-site; INR 420,000 - 900,000; Full time

Job summary

DJO Global in Hyderabad, India seeks a Senior Process Executive - Clinical Specialist to bridge clinical documentation with revenue cycle operations. The role focuses on accurate medical record review, coding support, and charge capture validation while ensuring payer compliance.

You will collaborate with providers, coders, billing teams, and payers, driving denial prevention and reimbursement optimization. 2–5+ years in US healthcare RCM/CDI is preferred.

Qualifications

• 2-5+ years of experience in US Healthcare RCM, CDI, Utilization Management, or Denial Management.
• Experience working with Medicare, Medicaid, and Commercial Insurance payers.
• Knowledge of medical necessity guidelines and payer policies.

Responsibilities

• Review medical records for completeness, accuracy, and payer compliance.
• Identify documentation gaps affecting coding and reimbursement.
• Support CDI initiatives and educate providers on documentation best practices.
• Analyze claims for denials and underpayments; assist in resolving denials.
• Validate medical necessity requirements based on payer policies.
• Collaborate with coders to ensure accurate ICD-10-CM, CPT, HCPCS coding.
• Monitor CMS/Medicare/Medicaid/commercial payer regulations and assist audits.
• Track denial trends and propose corrective actions.

Skills

Communication skills

Analytical abilities

Education

Bachelor's degree in Nursing

Bachelor's degree in Life Sciences

Tools

ICD-10-CM

CPT/HCPCS coding

EMR/EHR systems

Job description

Job Summary

The Senior Process Executive - Clinical Specialist serves as a bridge between clinical documentation and revenue cycle operations, ensuring accurate medical record review, coding support, charge capture validation, payer compliance, and denial prevention. This role collaborates with healthcare providers, coders, billing teams, and payers to optimize reimbursement while maintaining compliance with US healthcare regulations and payer guidelines.

The position requires strong communication skills, analytical abilities, and knowledge of revenue cycle management (RCM) to resolve claim issues, reduce outstanding AR, and improve cash flow. Additionally, the Senior Process Executive will mentor junior associates and contribute to process improvements.

Key Responsibilities

Clinical Documentation Review

• Review medical records to ensure completeness, accuracy, and compliance with payer requirements.
• Identify documentation gaps that may impact coding accuracy and reimbursement.
• Support Clinical Documentation Improvement (CDI) initiatives.
• Educate providers on documentation best practices.

Revenue Cycle Support

• Analyze claims for documentation-related denials and underpayments.
• Assist in resolving clinical denials, medical necessity denials, and authorization-related denials.
• Review appeals and prepare supporting clinical documentation.
• Ensure accurate charge capture and reimbursement optimization.

Coding Compliance Collaboration

• Work closely with medical coders to ensure accurate ICD-10-CM, CPT, and HCPCS coding.
• Validate medical necessity requirements based on payer policies.
• Monitor compliance with CMS, Medicare, Medicaid, and commercial payer regulations.
• Support internal and external audits.

Denial Management

• Investigate denied claims and identify root causes.
• Prepare clinical appeal letters and supporting documentation.
• Track denial trends and recommend corrective actions.
• Collaborate with AR and billing teams to reduce denial rates.

Education

• Bachelors Degree in Nursing, Life Sciences, Healthcare Administration, Pharmacy, or related healthcare field.
• RN (Registered Nurse), BPT, B.Pharm, M.Pharm, or equivalent clinical qualification preferred.

Experience

• 2-5+ years of experience in US Healthcare RCM, Clinical Documentation Review, CDI, Utilization Management, or Denial Management.
• Experience working with Medicare, Medicaid, and Commercial Insurance payers.
• Knowledge of medical necessity guidelines and payer policies.

Technical Knowledge

• ICD-10-CM
• CPT/HCPCS coding fundamentals
• Medical terminology
• Anatomy and physiology
• CMS guidelines
• Revenue Cycle Management processes
• EMR/EHR systems

Preferred Certifications

• Certified Clinical Documentation Specialist (CCDS)
• Certified Documentation Improvement Practitioner (CDIP)
• CPC, CCS, or CRC certification
• RN License (if applicable)

Job Title

Senior Process Executive - Clinical Specialist

Location

Hyderabad, India

Business Unit

Revenue Cycle Management

Disclaimer: This job posting has been aggregated from external source. Role details, content, and availability are subject to change. Applicants are advised to confirm the latest information directly on the company website before applying.