Manager - RCM Insurance

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.