Revenue Cycle Medical Billing
Resume:
SITHU ANIRUDHAN, COC, CPMB, CAIMC, FIMC®HCC, FIMC® Surgery,
ICD-10-CM Proficient
Trivandrum, Kerala +91-965******* ***********@*******.*** https://www.linkedin.com/in/sithu- anirudhan-coc-5ab10a17/
PROFESSIONAL SUMMARY
A visionary Revenue Cycle Management executive with 25 years of comprehensive experience in medical billing, coding, and operational excellence. Proven track record of driving strategic improvements, ensuring compliance, and optimizing revenue processes across diverse healthcare environments. Expertise in leveraging advanced technologies and AI to transform RCM operations. With a comprehensive background spanning multiple healthcare revenue cycle management domains, I bring over ten years of specialized expertise in Medical Coding across multiple specialties. My professional journey includes five years focusing on Hierarchical Condition Category (HCC) coding, with three years as Assistant Management role. I possess extensive seventeen years of experience in Revenue Cycle Management (RCM) end-to-end processing including fifteen years of team leadership experience. My professional skill set encompasses five years in Denial Management, handling facility and professional claims across diverse medical specialties. Additionally, I have cultivated specialized knowledge through one year of Credentialing experience, managing provider, clinic, hospital, and payer enrollments, and three years in Product Management - RCM side, where I focused on implementing billing and coding rules in Electronic Medical Records (EMR) systems to meet regulatory requirements in both the United States and United Arab Emirates. PROFESSIONAL QUALIFICATIONS / CERTIFICATIONS
Certified Professional Coder - Hospital (AAPC USA)
Certified Outpatient Coder (COC) (AAPC USA)
Proficiency Certificate in ICD-10-CM (AAPC USA)
Certified Professional Medical Biller (PMBA USA)
Certified AI Medical Coder (PMBA USA)
Fellowship in Medical Coding-HCC Coding (PMBA USA)
Fellowship in Medical Coding-Surgery (PMBA USA)
Certificate Course in HIPAA, GDPR, Data Security, and Data Protection (PMBA USA)
AI In Medical Billing and Coding (AAPC USA)
Lean Six Sigma Yellow Belt
Chat GPT & AI tools, Business Analysis using AI, Microsoft Copilot & Claude AI Mastery Bootcamp (Skill Nation)
IC-38 certified (Insurance Regulatory and Development Authority of India [IRDAI]) CORE COMPETENCIES
Strategic RCM Leadership
Quality Assurance Initiatives
Process Optimization
Denial Management
Compliance & Regulatory Adherence
Cross-functional Team Management
AI-driven RCM Transformation
Advanced Coding Techniques
PROFESSIONAL EXPERIENCE
SENIOR PRODUCT SPECIALIST Kameda Infologics Pvt. Ltd. Technopark, Trivandrum July 2021 – October 2024
o Expert in Yasasii features and applications, adept at resolving complex technical queries. o Develop comprehensive client-specific documentation on various product aspects. o Collaborate with technical teams to implement coding standards, ensuring accuracy and compliance.
o Provide strategic direction for the Revenue Cycle Management (RCM) team to support product enhancements and workflow optimization.
o Manage the product lifecycle from vision setting to release, defining roadmaps, and prioritizing RCM features.
o Proficient in overseeing product development, defining client requirements, and developing RCM product roadmaps.
o Skilled in troubleshooting issues and providing solutions to enhance product value and customer satisfaction.
o Work closely with the development team throughout product development stages to ensure RCM related features meet customer needs.
o Ensure EMR compliance with industry standards for data security and HIPAA regulations, safeguarding against cyber threats.
o Conduct regular training sessions on coding rule updates and their implementation within the EMR system.
o Ensure the EMR’s coding rule implementation complies with national and international standards.
o Customize the EMR system to meet the needs of clients in the UAE and the US, including template and coding tool customization.
o Regularly update EMR software to reflect the latest coding guidelines and regulatory changes. o Design EMR systems to minimize the risk of coding errors that could lead to claim denials or underbilling.
MANAGER - MEDICAL BILLING (RCM), MEDICAL CODING & DENIAL MANAGEMENT APLA Solutions LLC (In collaboration with Travanleo Info Solutions Pvt. Ltd. Technopark, Trivandrum) March 2019 - June 2021
o Oversee the entire medical billing process for both India and US offices. o Guide US staff in medical billing for home health, physical, occupational, and chiropractic services.
o Conduct training on the latest ICD-10-CM, CPT, and HCPCS coding guidelines, compliance, and insurance rules and regulations for government, commercial, private plans, and workers' compensation.
o Update coding rules, guidelines, and NCCI edits to reflect the latest changes. o Participate in healthcare software projects, including documentation of medical billing to coding in EMR transition processes, claim generation for different payers in ANSI 835 format, and analyzing and detecting loop errors in claims for integration. o Perform ERA auto-calculation for payment posting for various payers and generate reports according to client requirements.
KEY ACHIEVEMENTS
Reduced claim denials through proactive error detection.
Implemented AI-driven coding and billing processes.
Developed comprehensive documentation for RCM workflows.
Consistently maintained high accuracy in medical coding and billing. TEAM LEADER – MEDICAL BILLING & CODING GLG Technologies Pvt. Ltd., Technopark, Trivandrum September 2017 – August 2018
o Direct and coordinate the overall function of medical billing and coding. o Prepare detailed reports based on client requests. o Identify areas of under-documentation, cloned, and copy-pasted medical records. o Ensure compliance with electronic signature and attestation requirements. o Handle rejections, coding-related denials, and bundling issues based on NCCI. o Actively participate in all company-wide initiatives. SENIOR MEDICAL CODER – MULTISPECIALTY Medigain Health Pvt. Ltd., Adayar, Chennai March 2017 – September 2017
o Ensure accurate assignment of ICD-10-CM, ICD-10-PCS, CPT, and HCPCS codes based on patients' medical records.
o Manage service delivery goals through daily client calls, maintaining strong client relationships. o Lead client calls and share meeting minutes with clients. o Review and respond to coding questions, research coding issues, and provide updates. o Reconcile patient clinical notes to ensure compliance with HIPAA rules. o Provide coding documentation advice to clients for getting revenue. o Apply payer policies, Local Coverage Determinations (LCD), and National Coverage Determinations (NCD) for successful claim submissions. ASSISTANT MANAGER – MEDICAL CODING Armendale Healthcare Technologies Pvt. Ltd., Technopark, Trivandrum March 2014 – March 2017
o Oversee the accuracy of code assignments based on patients' medical records. o Ensure consistent and accurate code assignment by conducting team meetings with the medical coding unit.
o Reconcile clinic notes and patient encounter forms to ensure health information compliance with HIPAA rules.
o Conduct periodic team meetings to review past performance and provide feedback to employees.
o Plan, organize, and monitor all coding operations. o Provide coding documentation advice to coding units, clinical, and professional staff. o Analyze billing processes to improve coding data accuracy for Medicare compliance. o Ensure coded data accuracy reflects the services provided, preventing fraud and abuse. o Prepare patient profile sheets with drop-down codes in the MRA for diagnosis confirmation at the time of appointment, through daily appointment verification. o Analyze encountered diagnoses of members on service dates with their complete charts in HCC, providing provider queries for chronic cases. o Create EDI files and send claims through Gateway EDI using organization & PCP Tax IDs. o Confirm the acceptance of reported claims with KPI’s. o Analyze the MRA file to ensure the reported HCC diagnoses are accepted by insurance. o Prepare reports as requested by clients.
o Expert in detecting and correcting loop errors in EDI ANSI 5010 format in claims, especially for testing claims in new coding software.
TEAM LEAD– MEDICAL CODING, CLAIM ANALYSIS& CREDENTIALING Ariva Med Data Infotech Pvt. Ltd., Technopark, Trivandrum February 2008 – March 2014 o Analyze the accuracy in the assignment of ICD-9-CM, CPT, and HCPCS codes, and sequence diagnoses and procedures based on patients' medical records. o Ensure the medical coding unit assigns accurate codes. o Reconcile clinic notes, patient encounter forms, and health information to ensure compliance with HIPAA rules.
o Provide coding documentation advice to the coding unit, clinical, and professional staff. o Analyze billing processes to improve coding data accuracy for Medicare compliance reimbursement.
o Analyze encountered diagnoses with complete charts for HCC diagnoses and provider queries to verify dropped-down diagnoses for chronic cases. o Create EDI files and send claims through Gateway EDI using organization and PCP Tax IDs. o Analyze the status of claims in an organization and PCP Tax IDs to confirm acceptance. o Analyze MRA files to ensure reported HCC diagnoses are accepted by insurance. o Report confirmation of HCC drop-down codes to providers by prior appointment. o Analyze payments issued by insurance for hospital claims (DRGs, ICD-Vol-3 & CPT codes) and specialty claims referred by providers to specialists (coding issues, ICD-10-CM, ICD-10-PCS, HCPCS, CPT codes, contract fee rates, etc.) based on patient's medical records. o Analyze service fund files and review contested claims done by team members to validate reimbursement eligibility.
o Analyze and report high-cost claims achieved by members to clients. o Prepare reports as requested by clients.
o Expertise in detecting and correcting loop errors in EDI ANSI 5010 format in claims, particularly for testing claims in new coding software.
TEAM LEAD– MEDICAL BILLING & CODING Avida Mednet Pvt. Ltd., PMG, Trivandrum January 2006 – February 2008
o Oversee daily billing department functions, including medical billing & coding, charge entry, claims, payment posting, AR follow-ups, and reimbursement management. o Examine patient encounter forms with diagnosis codes and reconcile codes against services rendered.
o Accurately input procedure and diagnosis codes into billing software to generate invoices. o Use electronic charge capture practices, such as billing and accounts receivables in medical billing clearinghouse accounts, to submit codes and invoices on time. o Follow up on past due invoices/accounts to reduce unpaid and outstanding balances. o Review medical records and abstract ICD-9-CM, CPT, DRGs, and HCPCS codes. o Document patient data in medical records and perform audits to comply with payer requirements.
o Uphold and reinforce compliance with HIPAA for hospital policies and federal regulations. o Provide coding documentation advice to the coding unit, clinical, and professional staff. o Analyze billing processes to improve coding data accuracy for Medicare compliance reimbursement.
o Ensure coded data accurately reflects the services provided, safeguarding documents against fraud and abuse.
o Conduct training for billing rules, education regarding diagnosis, procedure code assignment, and regulatory requirements.
o Demonstrate working knowledge in claims & reimbursement for HMOs, PPOs, Medicare/Medicaid, and workers' compensation.
o Perform appointment verification through Eligibility verification for Deductible/copay to collect through E-clinic software.
o Handle rejections, coding-related denials, and resubmissions. o Prepare check requests for refund bills paid by patients/payers. o Reconcile bank statements with received payments. MEDICAL BILLING & CODING EXECUTIVE Med Data Infotech Pvt. Ltd., Pettah, Trivandrum November 1999 – December 2005
o Provide administrative support to physicians, interpreting medical report data to assign ICD-9- CM codes for diagnoses and CPT codes for treatments in patient records. o Stay updated on coding, sequencing, and procedural best practices and updates. o Review and validate the accuracy of charges, including dates of service, services provided, location, patient identification, and provider signatures. o Collect, post, and manage patient account payments, and prepare submitted claims forms for payers and other third-party administrators (TPAs). o Perform insurance verification, pre-certification, and pre-authorization. o Enter requisite patient information into billing software with procedure and diagnosis codes, modifiers, verified diagnoses, and coded narrative diagnoses to streamline invoicing and account management within the Claim Management process. COMPUTER INSTRUCTOR (MS OFFICE) Softech Computer Centre, Kollam May 1999 – November 1999
o Office administration and Trainer in MS Office.
TECHNICAL SKILLS
Medical Coding: ICD-10-CM, ICD-10-PCS, CPT, HCPCS
Billing Software: Medisoft, E-clinics, Yasasii, Epic
Claim Processing: EDI ANSI 5010, Electronic Claims Submission
AI Tools: Microsoft Copilot, ChatGPT integration in RCM EDUCATION
Bachelor of Science in Physics, Kerala University
Computer Diploma in Office Management, IHRD Trivandrum LANGUAGES
English (Fluent)
Hindi (Conversational)
Malayalam (Native)
PROFESSIONAL REFERENCES
Vivake Abraham, C.E.O., Apla Solutions L.L.C., Florida, U.S., Mbl# 001 813-***-****, email: ******.*******@*************.***
Sreedhar P.K., Director,Travanleo Info Solutions India Pvt. Ltd., Mbl# 940*******, email: **********@*********.***
Sankar Krishnan, C.E.O., Travanleo Info Solutions India Pvt. Ltd., Mbl# 944-***-****, email: *******@*********.***
Vidya Parameswaran, Director,Cezta L.L.C. New Port Richey, U.S., Mbl# 001 484-***-****, email: *******@*****.***
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