We are seeking a Process Analyst / Subject Matter Expert (SME) to provide deep domain expertise in the full US Healthcare Revenue Cycle Management (RCM) lifecycle, driving process optimization, AI/ML adoption, automation, and operational excellence.
The role spans the entire RCM cycle: Patient Registration Eligibility & Benefits Prior Authorization Coding & Documentation Charge Capture Claims Submission Payment Posting Denial Management Collections & Reporting.
The SME will focus on full RCM workflows, payer systems, EHR/EMR/PMS integrations, EDI transactions, coding standards, payer portals, and payer databases (e.g., NCCi, AAPC, AHIMA, AMA), ensuring compliant, scalable, and data-driven RCM operations and supporting analytics, AI/automation, and dashboard/reporting initiatives for US healthcare operations.
The role collaborates with business analysts, data scientists, RPA engineers, AI/ML teams, system/application analysts & developers, and clients to implement AI-driven process improvements.
End-to-End RCM Process Expertise:
- Analyze and optimize full RCM workflows, including Patient Registration, Eligibility Verification, Prior Authorization, Coding, Charge Capture, Claims Submission, Payment Posting, Denial Management, Collections, and Reporting.
- Map detailed process flows, exceptions, and system interactions for RCM operations.
- Maintain best-practice SOPs aligned with compliance, AI/automation, and system integrations.
- Leverage knowledge of payer databases, payer websites, and industry standards (NCCi, AAPC, AHIMA, AMA) to validate claims and workflows.
- Serve as domain expert across the full RCM cycle:
- Patient Registration & Scheduling
- Eligibility & Benefits Verification
- Medical Coding (ICD-10, CPT, HCPCS)
- Claims Submission & Management
- Denials Management & Collections
- Revenue Reconciliation & Financial Reporting
- Identify process gaps, inefficiencies, and automation opportunities within RCM workflows.
EHR/EMR/PMS & System Expertise:
- Work with EHR/EMR platforms, PMS systems, and integrated billing systems to align business processes with operational and AI workflows.
- Collaborate with System/Application Analysts to ensure workflows translate into functional requirements.
- Validate RPA, AI agents, and automation integrations within healthcare IT systems.
Payer & Market Intelligence
- Maintain expertise on payer systems, portals, and clearinghouses:
- Commercial payers: UnitedHealthcare, Anthem, Aetna, Cigna, Humana, Blue Cross/Blue Shield
- Government payers: Medicare, Medicaid
- Clearinghouses: Availity, Change Healthcare, Optum, RelayHealth, Trizetto
- Conduct market research on payer rules, reimbursement policies, adjudication workflows, and claims lifecycle.
- Maintain knowledge of professional coding & billing standards: AAPC, AHIMA, AMA CPT, ICD-10, HCPCS, NCCI edits.
AI/ML & Automation Enablement:
- Identify opportunities for AI/ML, GenAI, LLM-based agents, and Agentic AI in RCM workflows.
- Partner with data scientists and RPA engineers to operationalize predictive models, agentic AI, and automated decision-making.
- Support multi-agent orchestration, workflow automation, and analytics-driven process improvements.
Training, Mentorship & Knowledge Transfer:
- Serve as domain authority for cross-functional teams including AI, RPA, system analysts, and client stakeholders.
- Conduct training sessions, workshops, and knowledge transfer for RCM systems, AI workflows, and compliance processes.
- Develop process manuals, SOPs, and training materials integrating full RCM cycle knowledge with AI/automation best practices.
Technical Collaboration:
- Collaborate with Product, Engineering, Data, AI/ML, RPA, and DevOps teams to translate business and process requirements into technical solutions.
- Support design and validation of end-to-end RCM tools, including workflow automation, AI/GenAI models, and multi-agent orchestration.
- Work closely with data scientists, AI/ML engineers, cloud architects, RPA developers, and DevOps teams to ensure business requirements are translated into scalable, compliant solutions.
- Support LLM Ops, MLOps, and Agentic AI deployment by defining input/output requirements, monitoring KPIs, and validating results.
- Assist in integration of AI predictions and autonomous agent outputs into RCM and cloud workflows.
Analytics, Reporting & Insights:
- Define KPIs, dashboards, and reporting frameworks for operational, financial, and compliance performance.
- Collaborate with data and analytics teams to ensure data accuracy, integrity, and actionable insights.
- Conduct deep analysis of RCM projects, identifying trends, bottlenecks, and revenue optimization opportunities.
Compliance & Governance:
- Ensure adherence to HIPAA, SOC 2, GDPR, and internal healthcare compliance standards.
- Maintain audit-ready documentation for AI/ML models, RPA workflows, and process changes.
- Implement data governance and process validation frameworks for operational reliability.
Stakeholder Management:
- Serve as the liaison between technical teams, product owners, and business stakeholders.
- Facilitate workshops, requirement reviews, and solution validation sessions.
- Bachelor’s or Master’s degree in Healthcare Administration, Health IT, Business Analysis, or related field.
- 7–12+ years in US Healthcare RCM, with hands-on experience across full-cycle processes.
- Strong knowledge of payer systems, EHR/EMR, PMS, clearinghouses, and EDI standards.
- Experience collaborating with technical teams to design automated, AI-enabled, and analytics-driven RCM workflows.
- Proven understanding of coding, billing, claims adjudication, and healthcare compliance.
Technical Expertise:
- EHR/EMR & PMS: Epic, Cerner, Allscripts, Meditech, AthenaHealth, NextGen
- Payer Portals & Clearinghouses: Availity, Change Healthcare, Optum, RelayHealth, Trizetto
- EDI Standards: X12 837 (claims), 835 (remittance), 270/271 (eligibility), 276/277 (claim status), 278 (prior authorization)
- Coding & Compliance: ICD-10, CPT, HCPCS, NCCI edits, AAPC, AHIMA, AMA CPT
- Analytics & Reporting: SQL, Snowflake, Redshift, Tableau, Power BI
- AI & Automation Collaboration: Guide LLM Ops, Agentic AI, GenAI, and RPA workflow integration
Skillset:
- Deep understanding of end-to-end US RCM processes and payer ecosystems.
- Ability to analyze, document, and optimize complex workflows for automation and AI integration.
- Expertise in EDI transactions, payer rules, and coding compliance.
- Strong analytical, problem-solving, and reporting skills.
- Excellent communication, stakeholder management, and knowledge transfer skills.
- Experience in cross-functional collaboration with technical and operational teams.
- Ability to translate complex technical workflows into actionable business insights.
- Understanding in AI/ML, RPA, Agentic AI, and healthcare operations.
- Knowledge of compliance, governance, and audit standards.
- Ability to drive cross-functional collaboration and solution adoption.
Strategic Impact:
- Ensure comprehensive RCM process coverage across all modules and systems.
- Enable AI/automation adoption by providing domain and workflow expertise.
- Reduce process inefficiencies and claim denials, improving revenue and compliance.
- Bridge business operations and technical development for scalable RCM solutions.
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