Job Description

Description

The RCM Case Manager is responsible for overseeing and managing inpatient and outpatient case workflows, ensuring accuracy and compliance in claims submission, and providing support in the revenue cycle management (RCM) process. The role focuses on inpatient utilization review/management, optimizing operational efficiency, and handling complex claims related to OBGYN, NICU, and pediatric care. The Case Manager collaborates across departments, including physicians and nurses, to ensure proper documentation, reimbursement, and timely resolution of denials

Essential Job functions and Key Accountabilities:

5.1. Manage inpatient and outpatient case workflows, ensuring accurate documentation for reimbursement purposes.

5.2. Handle complex claims in specialties such as OBGYN, NICU, and pediatrics, and ensure proper coding and billing procedures.

5.3. Oversee the review and management of denied claims, including the resubmission process, ensuring timely follow-ups and resolutions.

5.4. Work with the billing department to ensure claims are submitted within the appropriate timeframe (preferably within 10 business days after service).

5.5. Collaborate with physicians, nurses, and other clinical staff to ensure optimal patient care documentation, ensuring alignment with reimbursement standards.

5.6. Provide oversight and training to clinical and RCM teams on coding accuracy, medical management, and quality indicators.

5.7. Act as a liaison between the hospital and insurance payers in matters related to billing, coding, and reimbursements.

5.8. Lead case management meetings and participate in multidisciplinary reviews to improve care and operational efficiency.

5.9. Ensure 100% claim submission within 30 days of service and maintain coding accuracy above 92%.

5.10. Develop and implement strategies to reduce claim rejections and improve overall revenue cycle performance.

5.11. Collaborate with finance and billing departments to ensure any outstanding accounts receivable (A/R) issues are resolved promptly.

5.12. Ensure all eligible accounts are appealed within the designated payer timeframes.

5.13. Assist in the physician query process to obtain additional documentation prior to final coding.

5.14. Provide regular reports on case management activities, claim statuses, and other RCM metrics.

5.15. Maintain a professional and collaborative working relationship with all stakeholders across the hospital.

Qualification

Bachelor's degree in healthcare administration, business, or a related field (life sciences background preferred).

Certifications: CPC, CCS, CDIP, or equivalent coding certification (DOH, DHA, or MOH certification accepted).

Experience

At least 2 years of strong experience in inpatient utilization review/management. Minimum of five (5) years of medical billing and/or coding management experience preferred. Minimum of three (3) years Inpatient and Outpatient coding experience in any setting i.e., hospital, clinic, or other related healthcare field is required. In addition to medical coding, knowledge of billing process will be a plus.