RCM Payer Escalations Director

Position Overview:

The RCM Payer Escalations, Director, will lead a team to strategically manage claims underpayment escalations, identifying qualifying claims through data reviews, and provide actionable insights to support Managed Care negotiations with third-party payers to ultimately drive claims reimbursement and resolution. You will build strong relationships across various RCM stakeholders, play a critical role in proactively auditing and reviewing claims for payer escalations, oversee entire workflow, monitor performance, and address revenue-impacting trends, using data analytics to optimize processes. To excel in this role, you must have extensive experience in medical billing and coding, strategic leadership, payer relations, data analytics, process optimization, and cross-functional collaboration within revenue cycle management and managed care teams.

Essential Duties and Responsibilities

• Work in close partnership with key RCM stakeholders to ensure alignment of strategies and organizational goals
• Lead and mentor a team of RCM professionals, acutely focused on underpayments and proper auditing for successful payer escalation
• Review, audit, and root-cause reasons for payment delays, to ensure proper escalations
• Develop and implement strategies to improve payer escalation processes
• Build, enhance, and maintain the systems and workflows needed to manage all escalated inventory
• Develop and monitor key performance indicators (KPIs) related to payer escalation
• Provide analytics on all aspects of the business, including real-time volumes, balances, resolution detail, resolution rates, and trends
• Prepare and present reports on payer performance and escalation outcomes to senior leadership on a routine basis
• Utilize data analytics to identify patterns and root causes of payer-related issues
• Monitor and analyze payer performance, identifying trends impacting revenue
• Lead a high-functioning team of AR resolution experts & drive leadership accountability to meet and exceed performance targets
• Develop team members to proactively identify and understand revenue cycle issues in conjunction with payor contracts and adjudication practices
• Conducts a strong team culture of collaboration, being in service to our partners, internal departments, and each other to drive results
• Implement best practices and innovative solutions to enhance efficiency and effectiveness
• Ensure compliance with industry regulations and standards throughout the escalation process

• Advanced experience in healthcare revenue cycle inventory management, with a strong understanding of medical billing and coding
• Demonstrated experience developing teams and processes to achieve top-level performance for respective RCM functions and performance objectives
• Demonstrated experience managing the complexities and nuances of matrix environments to drive alignment, accountability and performance objectives
• Possess a comprehensive understanding of RCM principles, processes and performance drivers spanning front, middle and back-end functions
• A minimum of ten (10) years of RCM leadership serving ASC and/or SH facilities, with a focus on payer relations and escalation
• In-depth knowledge of healthcare regulations and payer policies
• Proven leadership experience, with the ability to manage and motivate a team
• Strategic vision and operational excellence across end-to-end solutions
• Exceptional negotiation and problem-solving skills
• Excellent communication and interpersonal abilities
• Proficiency in data analysis and reporting tools
• Bachelor’s degree