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.