Specific Job Duties and Responsibilities:
● Achieve collection ratio, AR realization %, and forecast-accuracy targets while maintaining AR days, >90-day AR, and denial percentage within MGMA/HFMA industry benchmarks across all verticals.
● Own SLA/TAT adherence and productivity-per-FTE metrics across pre-claims and post claims teams, ensuring industry-leading performance and 99% clean-claims quality.
● Drive audit pass rates, error/quality scores, and CAPA closure timelines through Lean Six Sigma and PDCA-based quality governance, including RCA for recurring denial and payment issues.
● Oversee client escalations spanning charges, payments, AR, and denials, and collaborate with stakeholders for timely resolution.
● Ensure consistent adherence to SLAs across all teams and drive continuous process re engineering, automation, and technology adoption to reduce manual effort and cycle time.
General Responsibilities:
● Standardize SOPs and workflow documentation across pre-claims and post-claims verticals, maintaining version-controlled process libraries (Masterfiles) for AR, denial management, payment posting, and charge/demo entry.
● Design and maintain BCP/RA (business continuity and risk assurance) plans to safeguard uninterrupted claims processing.
● Build and review dashboards for AR realization, denial category/payer/physician analysis, and financial-class (payer-mix) reporting to support data-driven decision making.
● Ensure strict adherence to HIPAA, data-privacy, and payer/federal billing regulations, maintaining audit-ready documentation and internal controls in line with AAHAM and HFMA best practices.
● Serve as the primary escalation point and process authority for client leadership, leading Monthly Business Review (MBR) presentations and client transitions/onboarding for new projects.
● Own workforce planning, resource allocation, and capacity management across multi location pre-claims and post-claims teams, mentoring Team Leads/Managers as future leaders and playing a pivotal role in implementing solutions from all RCA.
● Be responsible for addressing escalations, both from clients and internally, and manage Change wherever required.
Daily Routine:
● Review overnight AR, denial, and charge/payment dashboards to identify early risks to collection ratio and AR days targets.
● Review client communications and escalation trackers, ensuring queries across pre claims and post-claims verticals are addressed promptly.
● Manage escalations by working closely with PH, Managers, and Senior Managers to implement solutions.
● Monitor daily productivity-per-FTE and SLA/TAT adherence across eligibility, charge entry, payment posting, and AR/denial teams.
● Ensure process adherence and track opportunities for operational improvements and automation.
Weekly Routine:
● Analyze denial trends, AR aging (including >90-day AR), and client performance against MGMA/HFMA benchmarks; develop corrective action plans (POA) and communicate strategies to the team.
● Review dashboards on denial category/payer/physician analysis and financial-class (payer-mix) reporting with Managers.
● Collaborate with Quality, Training, and Technology/Automation teams to address cross functional issues affecting both internal and external outcomes.
● Participate in L10 meetings to provide insights on performance and progress, and share strategic updates with all leaders to promote continuous optimization of processes. Monthly Routine:
● Review collection ratio, AR realization %, and forecast accuracy, and evaluate performance against established targets.
● Conduct one-on-one meetings with PHs/Managers to assess progress, address challenges, and provide coaching.
● Conduct monthly scorecard reviews with direct reports to track AR days, denial %, SLA/TAT, and audit pass rate.
● Review CAPA closure timelines and RCA outcomes from quality audits, and evaluate client performance metrics, initiating corrective measures where needed.
● Review quarterly goals with Managers to ensure alignment with company objectives, and lead Monthly Business Review (MBR) presentations with clients covering charges, payments, AR, and denials.
Quarterly Routine:
● Conduct quarterly performance evaluations of Managers and Senior Managers, providing feedback and development plans.
● Review quarterly objectives with Managers and ensure alignment with company and client targets.
● Develop and implement growth and leadership-pipeline plans for Team Leads and Managers to support career progression.
● Lead Quarterly Business Review (QBR) meetings with clients and stakeholders, including payer/provider contract and underpayment analysis, to assess outcomes and refine strategies.
Annual Routine:
● Review client Yearly Performance Reports (YPR) and annual audit outcomes, and ensure implementation of corrective measures for improvement.
● Oversee implementation of fee-schedule and payer policy changes to ensure continued compliance with payer updates.
● Communicate regulatory, federal billing, and HIPAA/compliance updates to the team, ensuring adherence at all levels.
● Contribute to annual company strategy planning meetings, align departmental goals accordingly, and set the team's annual certification roadmap (AAHAM/HFMA).
Measurables:
● Maintain AR days, >90-day AR aging, and denial percentage within MGMA/HFMA industry benchmark thresholds.
● Achieve collection ratio and AR realization % targets of 98%+ with 99% clean claims and high forecast accuracy.
● Sustain SLA/TAT adherence and productivity per FTE across pre-claims and post-claims verticals, with denials maintained below 7%.
● Achieve and sustain HIPAA compliance at 100%, with a strong audit pass rate and zero non-conformities.
● Maintain team attrition below 5%, and demonstrate training effectiveness and leadership-pipeline development.
● Support client retention through consistent service quality, timely resolution of escalations, and successful onboarding of new clients, delivering the “WoW”/“Moment of Truth” with clients.
● Implement automation and AI/RPA (AR/Denial tool) solutions to reduce manual processes and enhance productivity.
Required Qualifications:
● Bachelor's degree in any discipline (Science, Commerce, or Life Sciences background preferred); a healthcare administration or finance-related degree is an added advantage.
● 12+ years of overall RCM/U.S. healthcare experience, including a minimum of 5+ years in a senior leadership role (AR Manager, Senior Manager, or Delivery Manager) managing multi-client, multi-specialty operations.
● Demonstrated experience managing large teams across geographically distributed delivery locations, with a proven track record across 15–20+ medical specialties spanning professional (physician) and hospital/facility billing..
● Preferred certifications: CRCS – Certified Revenue Cycle Specialist (AAHAM), CRCR – Certified Revenue Cycle Representative (HFMA), and Lean Six Sigma Black Belt (LSSBB), CSPR – Payment & Reimbursement, CSBI – Business Intelligence, CSPPM – Physician Practice Management (all HFMA), and PMP (PMI).
Required Skills:
● Full-spectrum RCM knowledge: eligibility/benefits verification, charge & demo entry, payment posting, AR follow-up, denial management, appeals, and collections forecasting.
● Advanced proficiency in MS Excel (dashboards, pivots, macros), PowerPoint (client decks/MBRs), and Visio (process workflow mapping).
● Strong data analysis and visualization skills for large AR/denial datasets, including financial-class (payer-mix) and waterfall-method reporting.
● Working knowledge of federal healthcare billing regulations, payer policies, and HIPAA/data-privacy compliance requirements.
● Experience partnering with technical/development teams to build or automate AR/Denial tools and reporting systems (Business Analyst orientation).
● Expertise in identifying and mitigating financial risks in internal processes, and ability to define KPIs, monitor performance, and implement corrective actions (RCA/CAPA) for continuous improvement.
● Excellent client-facing communication, presentation, and stakeholder-management skills, with experience leading MBRs, QBRs, and transition governance calls.