RCM Insurance Manager

The RCM manager at Bupa CareConnect’s clinic is responsible for overseeing all insurance-related operations, ensuring alignment with local regulations including NPHIES, CHI guidelines, and payer policy requirements. The role ensures effective processing of approvals, transactions, and claims, while managing HIS system compliance, accurate coding, and timely reporting. The Insurance Manager acts as a key link between the medical and RCM teams, driving claim integrity, regulatory compliance, and operational efficiency within the clinic’s insurance functions.

Revenue cycle Operation

• Develop and maintain a strategic approach to the revenue cycle that aligns with the broader objectives of Bupa insurance.
• Collaborate with clinical and administrative departments to ensure a seamless integration between care delivery and insurance processing systems.
• Manage daily insurance workflows: approvals, rejections, transaction management within HIS.
• Align insurance flows with payer requirements and NPHIES transaction standards.
• Supervise authorization and order routing for covered and uncovered services.

Insurance Process management

• Review service and align them with documented diagnoses.
• Ensure pre-authorization requirements are met before claim submission.
• Validate that documentation supports medical necessity for all services.
• Check for duplicate or missed entries before submitting claims.
• Submit claims through NPHIES platform within timeline.
• Monitor payer portals for claim status and act on feedback.
• Investigate root causes of rejections and initiate corrections.
• Coordinate with RCM team for resubmission of rejected claims.
• Track aging claims and escalate long-pending cases.

Regulatory Compliance & Audit

• Stay current with updates to CHI and NPHIES regulatory requirements.
• Ensure documentation complies with MOH and CHI regulations.
• Conduct monthly internal reviews on insurance transactions.
• Maintain accurate records of all claim-related communications.
• Prepare documentation for regulatory or payer audits.
• Identify trends in non-compliance and recommend fixes.
• Engage with legal/compliance teams for risk assessments.
• Standardize EMR’s for audit readiness.
• Guide staff in applying compliance procedures during documentation.

Coordination with Medical and RCM Teams

• Organize regular coordination meetings with clinic medical staff.
• Support clinical teams in correct ICD and CPT code usage.
• Train clinicians on payer documentation requirements.
• Provide guidance on common documentation gaps causing denials.
• Serve as single point of contact for insurance queries from clinical staff.
• Escalate recurring medical documentation issues to RCM leadership.
• Align workflows to minimize turnaround time for approvals.
• Review physician orders for insurance compliance.

Reporting and Performance Monitoring

• Generate daily dashboards on approvals, rejections, and pending cases.
• Create weekly summaries of high-risk claims and issues.
• Track KPIs including TAT, resubmission rate, and clean-claim rate.
• Conduct monthly trend analysis for operational bottlenecks.
• Benchmark insurance performance vs internal targets.
• Submit performance insights to RCM leadership for decision-making.
• Recommend operational improvements based on data findings.
• Monitor system downtime or NPHIES issues and report impact.
• Analyze rejection reasons by payer and initiate targeted resolutions.

• Progressive experience in revenue cycle management within a healthcare setting.
• In-depth knowledge of billing, coding, reimbursement, and healthcare regulations.
• Experience with Health Information Systems (HIS) and clinical coding (ICD-10, CPT).
• Excellent communication skills, both verbal and written. 

Bachelor’s degree in medicine, Pharmacy or related healthcare field.