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Job Family Summary :
The Operations Department is responsible to manage end to end aspects of claims management back-office operations and manage the delivery team of the cluster and its associated processes like Preapproval OP, CRU OP& IP, Data entry OP& IP, Coding OP and Submission OP& IP. The department primarily works on main objective of reducing cost and increasing revenue through the optimization of processing and timely submission of claims in time with highest quality, so as to ensure the client receives the payment with minimal or no rejections.
Role Summary :
The Manager Operations RCM, is responsible to manage all aspects of claims processing throughout the claims cycle in the back-end for the assigned cluster and reporting to VP operations.
Manages overall activities of the back-office operations for the cluster adhering to compliance and TAT. Ensures timely submission of approvals, timely detection and obtaining of approval extension, daily OP & IP coding, timely closing of OP&1P encounters and forward to billing system at the back office.
The roles primary objective is to reduce operating cost while ensuring a smooth and swift movement of the claim through its cycle up till submission to payer. Improving productivity and reducing TAT through the optimization of processes and systems is the key scope of this role.
The Manager Operations RCM will contribute to the day-to-day operations on all issues related to the revenue cycle management function, provide analysis, create written processes and train others in implementing a cross functional revenue cycle team.
Primary Responsibilities :
Support the VP operations and finance team to stay on top of expenses occurring while calculating cost vs revenue and ensure the ratio is maintained which is set by the Leadership team
Assists with the development and implementation of RCM strategies, recommends process changes and improvement initiative to continuously improve the RCM process to maximize billing and collections.
Acquire in -depth knowledge of client needs and deliverables and ensure client is satisfied.
Promotes and maintains a positive professional image of Accumed and participates in projects as directed by Leadership team.
Ensures the complete span of control 150-200 FTE are aligned with the end goal and values of the organization.
Leads the team on the day-to-day operations and ensures the deliverables defined in scope of work are met.
Collaborates with other function and maintains a productive relationship.
Coaches teams as a subject matter expert and provide resolution to all issues and engage in individual development.
Motivates the team to adhere to SOP, policies and comply to process metric benchmarks.
Define key result areas and key performance indicators for the team members and monitor the performance of team members in a periodic manner and report to superior.
Coordinate with supervisors and team leaders to ensure efficient claims submission and payment processes for multiple clients as per the SLA defined in the contract.
Internal Audit of specified High value and High Risk claims with focus on Compliance and Revenue Optimization Update staff and the client on Regulator guidelines related to RCM billing activities and protocols to be followed periodically Provide weekly and monthly dashboards on capacity utilization and quality parameters to the superiors.
Do Root cause analysis of customer complaints and ensure the complaints are not repeated through awareness training, process re-engineering wherever needed.
Ensures the implementation of Key Performance Indicators (KPIs) with focus on reducing turnaround times and increasing productivity with Quality metrics achieved Conducts RCM training to back-office staff in various RCM functions as and when required.
Actively monitors operational performance to anticipate and meet the needs of leadership. Ensure KPI's within the team is established and instills accountability and ownership at the appropriate level
Develop audit reports on productivity to ensure all processors are able to meet and exceed their productivity targets Reviews and monitors all revenue cycle interfaces to identify issues and barriers to an effective revenue cycle process. Recommends and helps implement solutions.
Leads and/or participate in other revenue cycle projects as assigned. Reviews and maintains familiarity with payer contracts for the assigned clients/clusters Ensures all revenue cycle policies and procedures are created and updated regularly and ensures the information is distributed to and understood by all staff.
Compile and analyze data for billing errors and work on solutions to reduce billing errors.
Develops direct reports by defining roles/responsibilities and expectations, assigning and communicating performance and promoting professional growth and accountability.
Assists team in communicating and aligning work priorities with the organizational vision, mission, values, and service standards Any other tasks related to Revenue optimization and billing.
Exercise discretion and independent judgement with respect to matters of significance.
Responds to all telephonic and email queries from client and onsite team in a clear, concise and timely manner.
Job Requirements :
Clinical Background or paramedic by education / Masters degree in healthcare administration preferred
CPMA/ CCS/ CPC/COC certified (Coding certification) Proficient in coding all out patient type charts
ICD 10 CM/CPT experience and knowledge is a must.
Certified in PMP and Six Sigma Black Belt.
Ability to take direction from all levels
Exhibit a high level of individual initiative.
Effectively lead a team environment.
Candidates must also have good problem-solving skills and excellent oral &written communication skills
Prior leadership experience
Revenue cycle consulting experience, such as revenue cycle outsourcing, interim management or performance improvement preferred
5 years of claims processing experience in large healthcare or Health insurance operations
Experience working with project stakeholders/business leadership team
Proficient in Healthcare Revenue Cycle programs and Technology
Key Performance Indicators (KPI's):
Core KPIs
Reduce overall Turn Around Time
Increase productivity
Client satisfaction Index
Additional KPIs
Achieve 100% timely submission every month for assigned clients
Analyze, control and implement actions to minimize or eliminate Revenue Leakage for the assigned clients/cluster.
Build pool of Versatile Subject Matter Experts who can be future leaders.
