Revenue Operations & Clean Claim Manager
hace 10 días
Denver
This position manages revenue operations work queues, establishes clean-claim controls, monitors first-pass acceptance and rejection trends, and coordinates corrective actions when billing or documentation defects to place revenue at risk. The Manager partners closely with Order Management, Revenue Recovery, Payment Integrity & Revenue Performance, Revenue Systems Strategy & Business Optimization, Finance, Payer Relations, Compliance, Information Technology, and external vendors. Core Competencies • Revenue Operations Leadership: Leads claim creation, validation, submission readiness, and clean-claim workflows with clear priorities, ownership, service expectations, and accountability for quality, timeliness, and results., • Claims, Billing, and Clean-Claim Expertise: Applies strong knowledge of healthcare claims, payer requirements, billing rules, EDI workflows, and timely filing to ensure claims are complete, accurate, compliant, and submission-ready., • Quality, Risk, and Work-Queue Management: Maintains disciplined oversight of work queues, aging, quality controls, and escalations to reduce billing defects, protect timely filing, and minimize financial exposure., • Root-Cause Analysis and Process Improvement: Identifies recurring defects, rejection patterns, and workflow gaps and partners across teams to implement corrective actions and sustainable process improvements., • Data-Driven Decision-Making: Uses operational, quality, productivity, aging, and financial data to identify trends, prioritize work, evaluate performance, and support informed decisions., • Cross-Functional Collaboration and Communication: Partners effectively across operational, financial, technical, compliance, and payer-facing teams to resolve issues, strengthen handoffs, and maintain clear accountability., • Coaching, Accountability, and Follow-Through: Sets clear expectations and provides consistent coaching, feedback, and development while ensuring performance gaps, commitments, and corrective actions reach resolution. Essential Duties & Responsibilities Revenue Operations Leadership • Lead daily revenue operations and clean-claim activities within the assigned scope., • Establish work priorities, queue of ownership, service expectations, escalation standards, and quality requirements., • Ensure claims are assigned, reviewed, documented, corrected, submitted, and escalated consistently., • Monitor staffing capacity, workload distribution, productivity, quality, and turnaround time., • Lead employee selection, onboarding, coaching, cross-training, competency development, and performance management. Claim Creation, Validation, and Submission Readiness • Oversee claim creation and validation after the appropriate operational handoff and delivery milestone., • Confirm required billing data, payer information, codes, modifiers, units, dates, pricing, documentation references, and claim-format requirements are complete and accurate., • Apply approved payer and billing rules to determine claim readiness., • Prevent incomplete, unsupported, duplicate, or inaccurate claims from entering the submission workflow., • Ensure claims are submitted or released within applicable filing requirements and internal turnaround standards. Clean Claim and Billing Quality Management • Establish clean-claim review standards and quality control processes., • Monitor clean claim rate, first-pass acceptance rate, rejection rate, correction volume, and repeat billing defects., • Conduct or oversee targeted quality reviews based on risk, trend, payer, employee, product, code, or workflow., • Identify recurring billing defects and coordinate corrective actions with the appropriate business owner., • Maintain quality evidence, defect categories, corrective action records, and follow-up validation. Rejection, Exception, and Correction Management • Oversee rejected, suspended, returned, documentation-pending, and correction-required claim queues., • Define when an item can be corrected within Revenue Operations and when it must be returned to Order Management or another source of owner., • Monitor failed or incomplete GenHealth-enabled and NikoHealth-supported transactions., • Ensure exceptions include a clear reason, assigned owner, next action, due date, and escalation status., • Analyze rejection and exception trends and escalate systemic risks. Work-Queue and Timely Filing Governance • Maintain disciplined queue of ownership, aging standards, follow-up expectations, and escalation thresholds., • Monitor unbilled, held, rejected, returned, suspended, and unresolved claim activity., • Protect timely filing through proactive aging review and escalation., • Identify bottlenecks, stalled handoffs, and unresolved documentation dependencies., • Provide leadership visibility into claim volume, queue aging, financial exposure, and operational barriers. Cross-Functional Handoffs and Corrective Action • Partner with Order Management when missing or inaccurate upstream information affects claim readiness., • Provide structured feedback on authorization, documentation, payer, demographic, product, or order defects that create billing risk., • Partner with Revenue Recovery on denial and nonpayment trends requiring upstream billing correction., • Partner with Payment Integrity & Revenue Performance when financial findings indicate a claim-build, posting, adjustment, or workflow concern., • Partner with Revenue Systems Strategy & Business Optimization on business requirements, workflow redesign, SOP standards, UAT, and corrective-action implementation. Revenue Systems Support • Provide business requirements and operational subject matter expertise for GenHealth and NikoHealth billing workflows., • Participate in UAT, process validation, training, implementation of readiness, and stabilization activities., • Monitor automation exceptions, manual rework, output accuracy, and workflow adoption within Revenue Operations., • Escalate recurring workflow or configuration concerns to Revenue Systems Strategy & Business Optimization and the Operations Product Owner & Systems Administrator., • Maintain clear separation between business workflow ownership and technical system administration. Analytics and Reporting • Develop or maintain operational dashboards, queue reports, quality summaries, and clean-claim performance reporting., • Analyze claim volume, acceptance, rejection, correction, aging, productivity, and quality trends., • Quantify financial exposure associated with billing defects, held claims, untimely action, and unresolved exceptions., • Provide accurate, timely, and decision-ready reporting to department leadership., • Use performance data to coach employees, prioritize improvement of work, and validate results. Performance Expectations • Improve clean claim rate and first-pass acceptance rate., • Reduce preventable rejections, corrections, billing defects, and manual rework., • Maintain timely claim release and filing compliance., • Ensure revenue operations queues are assigned, current, documented, and escalated consistently., • Improve claim readiness and reduce unresolved handoff defects., • Provide timely and accurate operational reporting., • Convert recurring billing findings into sustainable corrective actions. Qualifications Minimum Qualifications • Bachelor's degree in healthcare administration, Business Administration, Finance, Operations Management, or a related field, or an equivalent combination of education and directly related experience., • Seven or more years of progressive healthcare billing, claims, revenue operations, or revenue cycle experience., • Three or more years of supervisory, team-lead, management, or formal cross-functional leadership experience., • Demonstrated knowledge of claim creation, billing requirements, corrections, rejections, EDI or clearinghouse workflows, timely filing, and work-queue management., • Experience managing productivity, quality, turnaround time, and operational performance., • Experience analyzing billing defects and implementing corrective actions., • Proficiency with Excel, healthcare billing systems, and operational reporting., • Strong communication, prioritization, documentation, and cross-functional leadership skills. Preferred Qualifications • DME/HME billing or revenue operations leadership experience., • Commercial, Medicare Advantage, Medicaid Managed Care, or multi-payer billing experience., • Experience with NikoHealth or a comparable DME/HME or healthcare revenue-cycle platform., • Experience supporting GenHealth or another automated claims, quality