Claim Scrubbing & Rule Engine Mastery in medical billing RCM

Master claim scrubbing, edits & rule engines for medical billing RCM, HIPAA/HITECH, BAA, protection, EDI, compliance IT!

What you'll learn
- Design end-to-end claim-scrubbing workflows that prevent denials before submission
- Build rule engines: data validation, coding edits, sequencing, medical necessity checks
- Map payer policies to edits (NCCI, LCD/NCD, bundling, frequency, age/gender, POS/TOB)
- Interpret EDI (837/835/277CA/999/TA1) and leverage interoperability to reduce rework
- Create taxonomy of edits (hard/soft, pre-bill/post-bill) with priorities and owners
- Implement HIPAA/HITECH safeguards, BAAs, audit trails, and data-protection controls
- Measure impact with KPIs (first-pass rate, DSO, denial prevent %, rework cost, yield)
- Integrate scrubbing with PMS/EHR, clearinghouses, BI tools, and downstream finance

Requirements
- Medical Billing Fundamentals
- Interest in insurance rules, coding, and revenue-cycle improvement
- Willingness to follow structured QA, version control, and governance processes
- No prior claim-scrubbing experience required (beginner-friendly)

Description
This course is designed to help learners of all backgrounds understand and applyclaim scrubbing and rule-engine techniques in medical billing and revenue cycle management (RCM)in real-world healthcare settings. Whether you’re working in medical coding, billing, administration, Healthcare IT, or compliance, this course emphasizesHIPAA, HITECH, Business Associate Agreements (BAA), data protection, data safety, insurance rules, and payer compliance—with hands-on practice buildingedits, validations, and rule enginesthat boost first-pass clean-claim rates.

You’ll learn how claim data quality is built using standardized fields, code sets, and validation logic—then apply a structured taxonomy of rules (demographics, eligibility, coding/bundling, medical necessity, frequency, prior auth, POS/TOB, COB) to intercept issues before submission. The course also covers interoperability andEDI—including how to interpret the feedback loops from837/999/277CA/835—and how to translate payer guidance (e.g., NCCI, LCD/NCD) into operational rules.

Designed to be beginner-friendly, this course offers clear explanations, interactive exercises, and realistic examples fromEHRs, claim files, payer responses, and billing documentationto help reinforce learning. No prior medical knowledge is needed.

What You’ll Learn

Understand the structure and components of high-quality claims and pre-bill edits

Learn rule-design patterns for demographics, coding, bundling, and medical necessity

Recognize terms used in payer edits, clearinghouse rejections, and denial codes

Apply claim scrubbing in clinical, coding, billing, and administrative contexts

Interpret chart notes, EDI acknowledgments, and payer responses with confidence

Strengthen communication across billing, compliance, and Healthcare IT teams

Prepare for roles in claim scrubbing, denial prevention, revenue integrity, or RCM analytics

Course Features

35+ video lessons organized by workflow, edit taxonomy, and system integration

Systematic breakdown ofrules & editswith real-life examples and test cases

Focus on high-impact scenarios (NCCI, LCD/NCD, frequency, modifiers, prior auth)

Easy-to-follow format, suitable for all learners—including ESL students

Accessible on mobile, desktop, or tablet

Who This Course Is For

Aspiring and current billers, coders, and RCM analysts focused on prevention

Practice managers and owners seeking higher first-pass rates and lower rework

Healthcare IT/compliance professionals implementingHIPAA/HITECHandBAAs

Anyone entering medical billing who needs practical, automation-ready skills

Mapped Sections (what you’ll cover step-by-step)

Foundations of Claim Scrubbing

Rules & Edits Taxonomy

Building & Operating a Rule Engine

EDI & Interoperability

Provider vs Payer Perspectives

Intermediate Claim Scrubbing Topics

Advanced/Expert Rule Strategies

Operations, QA & Governance

Metrics, KPIs & Economic Impact

Integration with PMS/EHR & Up/Downstream

Compliance, Security, Ethics

Tools & Implementation Patterns

Reporting & Executive Communication

Disclosure: This course contains the use of artificial intelligence for clear voiceovers.

Who this course is for:
- Medical billers/coders and AR specialists seeking pre-submission mastery
- Revenue integrity, RCM analysts, and denial-prevention teams
- Practice managers and compliance officers improving first-pass clean claims
- Healthcare IT/interop professionals connecting PMS/EHR, clearinghouse, and BI
- Quality/audit leads building edit governance, BAAs, and HIPAA/HITECH controls
- Students and career-changers entering insurance/RCM automation roles
More Info