RCM Functional SME

Job Description

Role : RCM Functional SME – Payer Systems

Location : Durham Nc (Hybrid)

C2C

2. Role Summary

The RCM Functional SME – Payer Systems will lead payer-focused Revenue Cycle Management assessments across the complete Claim-to-Cash lifecycle. The role will analyse payer interactions, claims processing, remittance, denials, and reimbursement workflows to reduce revenue leakage, improve collections, and strengthen payer-related operational efficiency.

3. Key Responsibilities

Lead functional analysis of payer-facing workflows across the end-to-end Claim-to-Cash lifecycle.

Assess 837P/837I claim transactions, claim edits, clearinghouse responses, and payer adjudication processes.

Evaluate 835 ERA processing, CARC/RARC codes, Coordination of Benefits, and remit reconciliation workflows.

Analyse denials, appeals, resubmissions, timely filing, payment variances, and patient responsibility management.

Review payer portals, eligibility and benefits, claim status, remit reconciliation, and clearinghouse behaviour to identify improvement opportunities.

4. Required Skills & Experience

10+ years of experience in healthcare Revenue Cycle Management with strong payer operations expertise.

Deep knowledge of 837P/837I, 835 ERA, CARC/RARC, claim adjudication, and reimbursement processes.

Experience with denials, appeals, resubmissions, Coordination of Benefits, timely filing, and revenue recovery.

Strong understanding of clearinghouse operations, payer portals, eligibility and benefits, claim status, and remit reconciliation.

Proven skills in process assessment, root-cause analysis, payment variance analysis, revenue-leakage identification, and stakeholder management.

5. Preferred Skills

Experience working with US commercial payers, Medicare, and Medicaid.

Knowledge of laboratory diagnostics, healthcare billing, payer rules, and reimbursement requirements.

Experience with Epic, Oracle Health/Cerner, Meditech, or comparable healthcare platforms.

Exposure to denial analytics, payment variance automation, workflow optimisation, or AI-enabled RCM solutions.

Good to have - Relevant certification in Revenue Cycle Management, medical billing, healthcare compliance, or Lean Six Sigma.