Medical Officer
1 week ago
Qualification and Experience:
Education: BDS/ BAMS/ BHMS/ BMBS
Experience: 4+ Year of experience in claim processing, quality assurance or audit in a health insurance or TPA setup.
Job Summary:
The Medical Officer Revenue Assurance is responsible for ensuring accuracy, compliance, and efficiency in the insurance claim process through structured quality audits, SOP implementation, and continuous process improvement. The role is to lead the successful implementation of revenue cycle solutions ensuring that the system supports front-end, mid-cycle, and back-end processes across healthcare organizations. You act as a bridge between clinical, financial, and technical teams, leveraging deep domain knowledge to ensure revenue optimization and compliance.
Key Skills:
RCM knowledge: Deep knowledge of healthcare RCM lifecycle, Charge capture, Coding, Billing, Denials, Payer rules.
Soft skills: Communication, critical thinking, documentation, stakeholder engagement.
Key Responsibilities:
Serve as the RCM expert for internal teams and clients.
Provide guidance on best practices for registration, eligibility, charge capture, coding, billing, collections, and denial management.
Ensure adherence to healthcare regulations.
Lead RCM system implementations for hospitals, physician groups, or health systems.
Define and document business and functional requirements based on client goals and workflows.
Collaborate with configuration teams to build system components such as claims logic, edits, fee schedules, payer rules.
Analyze existing client workflows and identify areas for improvement.
Map out optimized processes across the revenue cycle, from patient intake to collections.
Ensure alignment between clinical documentation and financial outcomes like accurate charge capture and compliant coding.
Oversee end-to-end testing for RCM functionalities
Conduct root cause analysis for issues in claims processing or denials.
Support go-live events with onsite or virtual assistance, ensuring smooth transition and adoption.
Educate client teams (front office, HIM, billing, coders) on new system workflows.
Deliver tailored training sessions and create documentation, manage change adoption and help teams adjust to new processes.
Develop dashboards or KPIs for RCM performance such as Days in A/R, Clean Claim Rate, Denial Rate.
Provide post-implementation support and optimization recommendations.
Provide post-implementation support and optimization recommendations.
Partner with revenue cycle stakeholders (registration, billing, coding, finance, IT) to understand business needs.
Gather, document, and analyze functional requirements for improvements to RCM systems and processes.
Translate business needs into system solutions or process changes.
Map current RCM workflows across front-end (e.g., eligibility checks), mid-cycle (e.g., coding), and back-end (e.g., collections).
Identify inefficiencies, revenue leakage, or compliance gaps.
Recommend changes to streamline operations and improve reimbursement.
Build dashboards or regular reports for operational leadership.
Assist with testing, validation, and post-implementation support.
Analyze system configuration issues that impact billing, claims, or reporting accuracy.
Help translate technical concepts into business-friendly language
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