This role proactively identifies, monitors, and mitigates enterprise revenue risks. It partners with Revenue Systems Strategy & Business Optimization, Billing Operations, Revenue Recovery, Financial Reconciliation, Payer Relations, and executive leadership to address revenue leakage, audit processes, validate payer and contract compliance, evaluate system performance, and improve reimbursement outcomes.
Critical Competencies- Revenue Integrity Expertise: Comprehensive understanding of revenue cycle operations, reimbursement methodologies, payment integrity, billing compliance, denial prevention, charge accuracy, and revenue leakage prevention.
- Strategic Analysis & Problem Solving: Ability to analyze complex operational, financial, reimbursement, and system-related issues to identify root causes, risks, and opportunities for improvement.
- Business Intelligence & Analytics: Advanced analytical capabilities with experience interpreting trends, performance metrics, operational data, and financial outcomes to support decision-making.
- Enterprise Governance & Controls: Knowledge of internal controls, auditing methodologies, compliance monitoring, process validation, and operational risk management.
- Revenue Performance Management: Ability to evaluate reimbursement trends, operational performance, payer outcomes, contract compliance, and revenue cycle effectiveness.
- Cross-Functional Leadership: Strong ability to influence stakeholders, facilitate collaboration, drive accountability, and lead initiatives without direct authority.
- Communication & Executive Presence: Ability to communicate findings, recommendations, risks, and strategic opportunities effectively to operational leaders and executive stakeholders.
Essential Duties & Responsibilities Enterprise Revenue Integrity Governance
- Serve as the organization's subject matter expert for revenue integrity and payment integrity initiatives.
- Develop and maintain enterprise revenue integrity monitoring programs.
- Identify risks impacting reimbursement accuracy, financial performance, and revenue recovery.
- Evaluate operational controls designed to prevent revenue leakage.
- Support the development of governance standards, policies, and best practices.
Revenue Leakage Prevention & Risk Management
- Identify trends contributing to revenue leakage across the revenue cycle.
- Monitor reimbursement accuracy and financial performance indicators.
- Evaluate denied claims, underpayments, write-offs, adjustments, and operational exceptions for emerging risks.
- Quantify financial impact and recommend corrective actions.
- Escalate significant revenue risks to leadership.
Payment Integrity & Compliance Oversight
- Conduct audits and reviews related to billing accuracy, documentation, authorizations, claims processing, and reimbursement.
- Validate payer configuration, reimbursement logic, fee schedule application, and system integrity.
- Monitor compliance with payer requirements, contractual obligations, and operational standards.
- Investigate reimbursement discrepancies and payment variances.
Revenue Performance Analytics
- Develop and maintain enterprise revenue integrity scorecards and KPI reporting.
- Analyze reimbursement performance, operational productivity, denial trends, aged receivables, and payer outcomes.
- Support executive reporting and strategic planning initiatives.
- Identify opportunities to improve revenue performance and operational effectiveness.
Strategic Business Partnership
- Partner closely with the Revenue Systems Strategy & Business Optimization team to identify operational improvement opportunities.
- Provide analytical support for strategic initiatives, automation efforts, workflow redesign, and system optimization projects.
- Assist in evaluating the effectiveness of implemented process improvements.
- Participate in enterprise transformation initiatives impacting revenue cycle performance.
Contract & Payer Performance Monitoring
- Support payer governance initiatives through monitoring and analysis of reimbursement outcomes.
- Identify contract variance trends, underpayment risks, and reimbursement discrepancies.
- Assist in validating payer implementation, fee schedules, reimbursement methodologies, and contractual compliance.
- Provide recommendations to improve payer performance and reimbursement outcomes.
Audit, Controls & Continuous Improvement
- Develop and execute audit plans focused on revenue integrity and payment of integrity.
- Monitor operational adherence to policies, procedures, and reimbursement requirements.
- Identify control weaknesses and recommend mitigation strategies.
- Track corrective action plans and process improvement initiatives through completion.
- Promote a culture of continuous improvement and accountability.
Documentation & Reporting
- Maintain accurate documentation of audits, findings, analyses, recommendations, and corrective action plans.
- Prepare written reports, dashboards, executive summaries, and presentations.
- Present findings and recommendations to leadership and key stakeholders.
- Support reporting requirements related to compliance, reimbursement performance, and operational effectiveness.
Minimum Qualifications Required
- Bachelor's degree in business administration, Healthcare Administration, Finance, Accounting, Analytics, Revenue Cycle Management, or related field; equivalent experience may be considered.
- Five (5) or more years of progressive experience in revenue cycle management, revenue integrity, payment integrity, reimbursement, healthcare finance, business analytics, operational excellence, or related functions.
- Demonstrated experience evaluating complex operational, financial, and reimbursement-related issues.
- Advanced analytical and problem-solving skills.
- Strong proficiency with reporting tools, data analysis, Microsoft Excel, and healthcare operational systems.
- Excellent communication, presentation, collaboration, and stakeholder management skills.
- Ability to lead cross-functional initiatives without direct supervisory authority.
Preferred
- Experience in DME, HME, respiratory therapy, infusion, home health, or related healthcare sectors.
- Experience supporting revenue integrity, payment integrity, payer governance, contract management, business optimization, or operational excellence initiatives.
- Experience with NikoHealth, healthcare ERP systems, business intelligence platforms, or revenue cycle technologies.
- Lean, Six Sigma, project management, compliance, auditing, or analytics certifications.
Success will be measured against the following Key Performance Indicators (KPIs) once performance benchmarks and baseline expansions have been established. - Revenue Leakage Prevention: Value of identified and mitigated revenue leakage opportunities.
- Payment Integrity: Billing accuracy, reimbursement accuracy, and compliance audit outcomes.
- Revenue Performance Analytics: Timeliness, accuracy, and effectiveness of reporting and analysis.
- Risk Identification & Resolution: Identification, prioritization, and mitigation of revenue risks.
- Process Improvement Impact: Measurable financial and operational improvements resulting from recommendations.
- Audit & Governance Effectiveness: Completion of audits, corrective action tracking, and compliance monitoring activities.
- Payer & Contract Performance Monitoring: Identification of contract variances, underpayments, and reimbursement discrepancies.
- Strategic Partnership & Influence: Successful support for enterprise initiatives, operational improvements, and executive decision-making.
