This position manages revenue operations work queues, establishes clean-claim controls, monitors first-pass acceptance and rejection trends, and coordinates corrective actions when billing or documentation defects to place revenue at risk. The Manager partners closely with Order Management, Revenue Recovery, Payment Integrity & Revenue Performance, Revenue Systems Strategy & Business Optimization, Finance, Payer Relations, Compliance, Information Technology, and external vendors.
Core Competencies- Revenue Operations Leadership: Leads claim creation, validation, submission readiness, and clean-claim workflows with clear priorities, ownership, service expectations, and accountability for quality, timeliness, and results.
- Claims, Billing, and Clean-Claim Expertise: Applies strong knowledge of healthcare claims, payer requirements, billing rules, EDI workflows, and timely filing to ensure claims are complete, accurate, compliant, and submission-ready.
- Quality, Risk, and Work-Queue Management: Maintains disciplined oversight of work queues, aging, quality controls, and escalations to reduce billing defects, protect timely filing, and minimize financial exposure.
- Root-Cause Analysis and Process Improvement: Identifies recurring defects, rejection patterns, and workflow gaps and partners across teams to implement corrective actions and sustainable process improvements.
- Data-Driven Decision-Making: Uses operational, quality, productivity, aging, and financial data to identify trends, prioritize work, evaluate performance, and support informed decisions.
- Cross-Functional Collaboration and Communication: Partners effectively across operational, financial, technical, compliance, and payer-facing teams to resolve issues, strengthen handoffs, and maintain clear accountability.
- Coaching, Accountability, and Follow-Through: Sets clear expectations and provides consistent coaching, feedback, and development while ensuring performance gaps, commitments, and corrective actions reach resolution.
Essential Duties & ResponsibilitiesRevenue Operations Leadership
- Lead daily revenue operations and clean-claim activities within the assigned scope.
- Establish work priorities, queue of ownership, service expectations, escalation standards, and quality requirements.
- Ensure claims are assigned, reviewed, documented, corrected, submitted, and escalated consistently.
- Monitor staffing capacity, workload distribution, productivity, quality, and turnaround time.
- Lead employee selection, onboarding, coaching, cross-training, competency development, and performance management.
Claim Creation, Validation, and Submission Readiness
- Oversee claim creation and validation after the appropriate operational handoff and delivery milestone.
- Confirm required billing data, payer information, codes, modifiers, units, dates, pricing, documentation references, and claim-format requirements are complete and accurate.
- Apply approved payer and billing rules to determine claim readiness.
- Prevent incomplete, unsupported, duplicate, or inaccurate claims from entering the submission workflow.
- Ensure claims are submitted or released within applicable filing requirements and internal turnaround standards.
Clean Claim and Billing Quality Management
- Establish clean-claim review standards and quality control processes.
- Monitor clean claim rate, first-pass acceptance rate, rejection rate, correction volume, and repeat billing defects.
- Conduct or oversee targeted quality reviews based on risk, trend, payer, employee, product, code, or workflow.
- Identify recurring billing defects and coordinate corrective actions with the appropriate business owner.
- Maintain quality evidence, defect categories, corrective action records, and follow-up validation.
Rejection, Exception, and Correction Management
- Oversee rejected, suspended, returned, documentation-pending, and correction-required claim queues.
- Define when an item can be corrected within Revenue Operations and when it must be returned to Order Management or another source of owner.
- Monitor failed or incomplete GenHealth-enabled and NikoHealth-supported transactions.
- Ensure exceptions include a clear reason, assigned owner, next action, due date, and escalation status.
- Analyze rejection and exception trends and escalate systemic risks.
Work-Queue and Timely Filing Governance
- Maintain disciplined queue of ownership, aging standards, follow-up expectations, and escalation thresholds.
- Monitor unbilled, held, rejected, returned, suspended, and unresolved claim activity.
- Protect timely filing through proactive aging review and escalation.
- Identify bottlenecks, stalled handoffs, and unresolved documentation dependencies.
- Provide leadership visibility into claim volume, queue aging, financial exposure, and operational barriers.
Cross-Functional Handoffs and Corrective Action
- Partner with Order Management when missing or inaccurate upstream information affects claim readiness.
- Provide structured feedback on authorization, documentation, payer, demographic, product, or order defects that create billing risk.
- Partner with Revenue Recovery on denial and nonpayment trends requiring upstream billing correction.
- Partner with Payment Integrity & Revenue Performance when financial findings indicate a claim-build, posting, adjustment, or workflow concern.
- Partner with Revenue Systems Strategy & Business Optimization on business requirements, workflow redesign, SOP standards, UAT, and corrective-action implementation.
Revenue Systems Support
- Provide business requirements and operational subject matter expertise for GenHealth and NikoHealth billing workflows.
- Participate in UAT, process validation, training, implementation of readiness, and stabilization activities.
- Monitor automation exceptions, manual rework, output accuracy, and workflow adoption within Revenue Operations.
- Escalate recurring workflow or configuration concerns to Revenue Systems Strategy & Business Optimization and the Operations Product Owner & Systems Administrator.
- Maintain clear separation between business workflow ownership and technical system administration.
Analytics and Reporting
- Develop or maintain operational dashboards, queue reports, quality summaries, and clean-claim performance reporting.
- Analyze claim volume, acceptance, rejection, correction, aging, productivity, and quality trends.
- Quantify financial exposure associated with billing defects, held claims, untimely action, and unresolved exceptions.
- Provide accurate, timely, and decision-ready reporting to department leadership.
- Use performance data to coach employees, prioritize improvement of work, and validate results.
Performance Expectations- Improve clean claim rate and first-pass acceptance rate.
- Reduce preventable rejections, corrections, billing defects, and manual rework.
- Maintain timely claim release and filing compliance.
- Ensure revenue operations queues are assigned, current, documented, and escalated consistently.
- Improve claim readiness and reduce unresolved handoff defects.
- Provide timely and accurate operational reporting.
- Convert recurring billing findings into sustainable corrective actions.
QualificationsMinimum Qualifications
- Bachelor's degree in healthcare administration, Business Administration, Finance, Operations Management, or a related field, or an equivalent combination of education and directly related experience.
- Seven or more years of progressive healthcare billing, claims, revenue operations, or revenue cycle experience.
- Three or more years of supervisory, team-lead, management, or formal cross-functional leadership experience.
- Demonstrated knowledge of claim creation, billing requirements, corrections, rejections, EDI or clearinghouse workflows, timely filing, and work-queue management.
- Experience managing productivity, quality, turnaround time, and operational performance.
- Experience analyzing billing defects and implementing corrective actions.
- Proficiency with Excel, healthcare billing systems, and operational reporting.
- Strong communication, prioritization, documentation, and cross-functional leadership skills.
Preferred Qualifications
- DME/HME billing or revenue operations leadership experience.
- Commercial, Medicare Advantage, Medicaid Managed Care, or multi-payer billing experience.
- Experience with NikoHealth or a comparable DME/HME or healthcare revenue-cycle platform.
- Experience supporting GenHealth or another automated claims, quality, or workflow solution.
- Experience with claim quality, rejection management, process improvement, or system implementation.
- Lean, Six Sigma, project management, billing, coding, or revenue-cycle certification.
Key Performance Indicators- Clean claim rate and first-pass acceptance rate
- Rejection, correction, and billing defect rates
- Unbilled volume, backlog, and queue aging
- Timely filing compliance and claim release turnaround
- Productivity and work completed per FTE
- Exception resolution and corrective-action closure
- Automation exception rate, output accuracy, and manual intervention
- Operational reporting timeliness and dashboard accuracy
General Employment Expectations- Maintain accurate and timely documentation in NikoHealth and other authorized systems.
- Follow approved workflows, internal controls, escalation procedures, privacy requirements, and department policies.
- Meet established productivity, quality, accuracy, timeliness, and financial performance expectations.
- Protect confidential patient, payer, employee, contract, and financial information.
- Participate in training, system testing, workflow stabilization, and continuous improvement activities.
- Collaborate professionally across Order Management, Patient Experience, Revenue Recovery, Payment Integrity, Revenue Systems Strategy, Finance, Payer Relations, Contracting, Compliance, IT, vendors, and other stakeholders.
- Perform other related duties consistent with the position's purpose and level of responsibility.
