RCM Benefits & MOHS Claims Lead

Job description

**RCM Benefits & MOHS Claims Lead** At Optima Dermatology, our mission to revolutionize skin care is made possible by our world-class team that is highly engaged, mission-driven, and inspired to set the new standard in dermatology. We are growing rapidly and looking for key team members who believe in our mission and want to make a difference in the lives of our patients. We foster a collaborative environment that is fun and hardworking, and we promise you will work alongside amazing colleagues you are proud to call your teammates. **Department:** Revenue Cycle Management, Patient Support Center **Location:** Patient Support Center, headquartered in Portsmouth, NH **Work Setting:** Remote or hybrid; must reside in NH, MA, NC, ME, IN, OH or FL **Employment Type:** Full-Time **Reports To:** Claims and EDI Manager **FLSA Status:** Salary - Exempt **Position Summary** The RCM Benefits & MOHS Claims Lead supports Optima Dermatology's mission by ensuring accurate insurance workflows, timely prior authorizations, and clean claims submission for MOHS and dermatology providers. This role serves as the operational lead and subject matter expert across eligibility verification, benefit interpretation, referral management, MOHS authorization review, peer-to-peer coordination, and MOHS claims processing. This is an individual-contributor lead role. It does not carry formal supervisory authority. Instead, the Lead provides daily guidance, escalation support, and workflow leadership to two specialist functions: - Insurance Verification & Authorization Specialists (eligibility, benefits, referrals, authorizations) - Claims & EDI Specialists (X12 submissions, edit corrections, clean claims) Through this guidance, the Lead ensures high accuracy, reduced denials, and a seamless patient and provider experience across dermatology and MOHS services, while supporting both front-end and back-end revenue cycle operations. **Primary Responsibilities** **Eligibility, Benefits & Coverage** - Oversee timely and accurate verification of insurance eligibility, benefits, and coverage requirements for dermatology and MOHS appointments. - Serve as the escalation point for complex coverage issues, coordination of benefits, payer-specific benefit interpretation, and demographic discrepancies. - Ensure eligibility, benefit, referral, and authorization information is documented accurately across all business systems. - Support Specialists and field operations with demographic verification, insurance updates, pharmacy details, referral questions, and preregistration workflows. - Provide day-to-day workflow direction and guidance to Insurance Verification & Authorization Specialists. **Authorization Management** - Lead submission, tracking, and management of prior authorizations, including staged procedures, pathology components, grafts, and reconstructive repairs. - Review clinical documentation and ensure appropriate CPT/ICD-10 codes are selected prior to authorization submission and claims processing. - Coordinate peer-to-peer reviews between providers and payers. - Manage authorization denials, including documentation collection, resubmissions, and escalation. - Provide workflow guidance and coaching to staff involved in authorization workflows. **MOHS Claims Processing** - Oversee complete MOHS claims submission to ensure accuracy, compliance, and timely filing. - Review operative notes, pathology reports, and coding for correct CPT/ICD-10 assignment across MOHS stages, repairs, grafts, and add-on procedures. - Ensure authorizations and referrals are properly linked to claims prior to submission. - Support clean claims by ensuring all insurance prerequisites are met before appointments or surgeries. - Partner with EDI and RCM teams to resolve claim errors, rejections, and payer requests. - Monitor MOHS claim trends, reimbursement patterns, and denial drivers. - Provide day-to-day workflow direction and guidance to Claims & EDI Specialists. **Workflow Leadership & Collaboration** - Act as the primary liaison between MOHS surgeons, dermatology providers, medical assistants, reception, EDI, and RCM teams to ensure seamless communication and workflow coordination. - Coordinate and schedule MOHS surgery appointments when needed, ensuring all insurance prerequisites, authorizations, and documentation are completed prior to scheduling. - Provide guidance and subject-matter expertise to Specialists performing eligibility, referral, authorization, and claims tasks. - Assist in developing, updating, and maintaining SOPs for eligibility, referral management, authorization workflows, and MOHS claims submission. - In conjunction with the Claims and EDI Manager, develop, refine, and maintain KPI metrics for eligibility, benefits, referrals, authorizations, and MOHS claims workflows. - Run analytics and operational performance reviews to identify trends, denial drivers, workflow gaps, and opportunities for improvement across authorization and insurance processes. - Identify workflow gaps and implement improvements to reduce denials, accelerate turnaround times, and enhance accuracy. - Support KPI monitoring across the team, including accuracy rates, denial rates, documentation compliance, and inquiry response times. - Maintain accurate records in the EHR, billing systems, and payer portals; assist with audits, reporting, and payer communications as needed. - Demonstrate Optima's values in all interactions with empathy, positive intent, and professionalism. **Position Requirements** - High school diploma or equivalent; coursework in business administration or accounting preferred. - Minimum of five (5) years of healthcare reimbursement, patient access, insurance verification, or related experience. - Strong working knowledge of medical and insurance terminology, eligibility and benefit interpretation, and professional claims workflows. - Experience with authorizations, including MOHS procedures and/or surgical claims, strongly preferred. - Experience with ModMed or a comparable dermatology EHR and practice-management system preferred. - Outstanding communication skills with the ability to educate internal partners and support providers. - Demonstrated problem-solving skills, attention to detail, and ability to prioritize in a fast-paced environment. - Ability to work independently and collaboratively across a distributed organization. - Experience providing guidance or workflow leadership to operational staff preferred. - Commitment to confidentiality and compliance with HIPAA and organizational policies. **Physical & Environmental Demands** This is a primarily sedentary, computer-based role performed in a remote or hybrid office environment. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. - Prolonged periods of sitting and working at a computer. - Extensive use of a keyboard, monitor, and telephone or headset. - Ability to communicate clearly by phone, video, and in writing throughout the workday. - Occasional travel to the Portsmouth, NH Patient Support Center or clinic sites may be required. **Equal Employment Opportunity** Optima Dermatology is an Equal Opportunity Employer. We are committed to building a diverse and inclusive workplace and do not discriminate on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, genetic information, or any other characteristic protected by applicable law. We provide reasonable accommodations to qualified individuals with disabilities throughout the application process and employment.