RCM — Priya
Priya is the Biller / RCM Specialist. She scrubs claims pre-submission, posts EOBs, works denials, files appeals, follows up on aged AR, and reconciles ERAs. She may be in-house or in the contracted RCM tier.
Pain Points
- Disconnected clearinghouse and EHR — claims submitted in one tool, denials worked in another, with no single source of truth for status.
- Denials triage that is fully manual — re-coding, paperwork, appeal letters typed from scratch.
- No visibility into why a particular code is failing across multiple claims and payers — pattern detection is a spreadsheet exercise.
Goals within REV.health
- Unified work queues with configurable views by payer, denial reason, dollar amount, and aging bucket.
- AI-tagged denial root cause with recommended next action and pre-drafted appeal letters seeded from clinical documentation.
- Recurring-denial dashboard that surfaces patterns across the practice and links back to coding or eligibility upstream.
Modules Touched
Day in the Life
Here's your workload for today:
23
Follow-ups
4.5 hrs
Estimated work time
2:30 pm
Done by
$14,200
Revenue recovered
- Open claim queue — 24 claims pending scrub from yesterday's encounters.
- AI scrub results — 22 clean (auto-submit), 2 flagged for review.
- Review flagged claims — one has mismatched diagnosis-support, one has missing modifier.
- Fix and submit — both corrected and submitted to clearinghouse.
- Denial queue — 8 new denials overnight from 3 payers.
- AI root-cause tags — 4 are eligibility-related (patient coverage lapsed), 3 are coding-related, 1 is duplicate.
- Batch-process eligibility denials — re-verify coverage, 3 of 4 now active; resubmit.
- Coding denials — review clinical docs, add supporting documentation, draft appeal letters using AI-generated templates.
- Aged AR review — 12 claims over 60 days; prioritize by dollar amount.
- Follow-up calls to 3 payers — 2 promises to pay, 1 needs written appeal.
- ERA reconciliation — 18 payments posted automatically, 3 need manual review.
- Dashboard — clean-claim rate 98.2%, days-in-AR 28, denial rate 4.1%.