Job Description
Is responsible for overseeing the RCM operations including claims and billing management. Communicate partner providers, implement and refine processes of audit and compliance, execute special RCM projects and participate in different analytical activities
Claims and billing management
- 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.
- Oversee the claims submission process to insurance providers, ensuring accuracy and compliance with insurance policies.
- Ensure that all claims, denials, and appeals are efficiently processed, and for resolving billing related issues.
- Identify opportunities to optimize revenue collection and cost management.
- Deliver metrics and reporting to monitor and improve revenue operations effectiveness
Partner Providers management
- Conduct comprehensive market analysis to identify potential partner providers.
- Establish and maintain robust relationships with providers. Negotiate favorable terms in contracts, provide regular feedback. review and evaluate partner performance against contracts and SLAs
- Implement strategies to ensure continuous improvement in partner performance.
- Develop and maintain a comprehensive database of partner providers.
- Work closely with the legal team to ensure compliance in partner contracts
Audit and compliance
- Develop and maintain a compliance risk management plan.
- Address audit findings with stakeholders and implement corrective actions.
- Review and update compliance policies and procedures regularly and monitor industry changes.
- and adjust compliance strategies accordingly.
- Ensure compliance with Coding & billing regulation.
- Provides education and policy updates for staff on a regular and as needed basis
- Conduct on-site audits of selected referral providers to validate the accuracy of documentation and compliance with established protocols.
- Establish a feedback loop to communicate audit findings with referral providers, addressing areas for improvement and acknowledging positive practices.
Projects management
- Identify process gaps and propose innovative solutions.
- Document and implement new workflows and processes.
- Establish cross-functional collaboration for successful project execution.
- Conduct regular project review meetings and provide status updates.
- Ensure project deliverables meet quality standards and organizational objectives.
- Evaluate project outcomes and capture learnings for future projects.
- Utilize project management tools and software for efficient tracking.
Healthcare Data Analysis
- Generate insights in certain healthcare specialties, mine patient and healthcare provider data from multiple sources to discover key analytical insights to create complete views of health data and cost trends.
- Maintain the different models for predictive analysis to evaluate members patterns of health care.
- Enhance the approaches for advanced patient risk stratification based on conditions, complexity, and medication profiling.
- Conduct cost-effectiveness analysis to identify alternate management options that provide medically necessary potentially cost-effective services.
Skills
- Communication skills
- Analytical skills
- Technical skills related to Claims Management and HIS
- Project Management skills
