Role : RCM Functional SME – Payer Systems
\nLocation : Durham Nc (Hybrid)
\nC2C
\n \n2. Role Summary
\nThe 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.
\n3. Key Responsibilities
\nLead functional analysis of payer-facing workflows across the end-to-end Claim-to-Cash lifecycle.
\nAssess 837P/837I claim transactions, claim edits, clearinghouse responses, and payer adjudication processes.
\nEvaluate 835 ERA processing, CARC/RARC codes, Coordination of Benefits, and remit reconciliation workflows.
\nAnalyse denials, appeals, resubmissions, timely filing, payment variances, and patient responsibility management.
\nReview payer portals, eligibility and benefits, claim status, remit reconciliation, and clearinghouse behaviour to identify improvement opportunities.
\n4. Required Skills & Experience
\n10+ years of experience in healthcare Revenue Cycle Management with strong payer operations expertise.
\nDeep knowledge of 837P/837I, 835 ERA, CARC/RARC, claim adjudication, and reimbursement processes.
\nExperience with denials, appeals, resubmissions, Coordination of Benefits, timely filing, and revenue recovery.
\nStrong understanding of clearinghouse operations, payer portals, eligibility and benefits, claim status, and remit reconciliation.
\nProven skills in process assessment, root-cause analysis, payment variance analysis, revenue-leakage identification, and stakeholder management.
\n5. Preferred Skills
\nExperience working with US commercial payers, Medicare, and Medicaid.
\nKnowledge of laboratory diagnostics, healthcare billing, payer rules, and reimbursement requirements.
\nExperience with Epic, Oracle Health/Cerner, Meditech, or comparable healthcare platforms.
\nExposure to denial analytics, payment variance automation, workflow optimisation, or AI-enabled RCM solutions.
\nGood to have - Relevant certification in Revenue Cycle Management, medical billing, healthcare compliance, or Lean Six Sigma.
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