RCM Optimization Specialist

About the position

The RCM (Revenue Cycle Management) Optimization Specialist supports operational enhancement of the revenue cycle by ensuring accurate membership data, provider roster alignment, payer integration, and performance tracking. This role functions as a subject matter expert that will work with payers focusing on reducing attribution leakage and identifying process gaps. The specialist also serves as a super-user of revenue systems and membership validation platforms and plays a critical role, working closely with RCM Optimization Manager and Analyst, in implementing dashboards, workflows, and tools that promote data-driven decision-making and regulatory compliance.

Responsibilities

• Provides daily administration and coordination of RCM Optimization functions
• Performs daily validation of membership files to ensure alignment across eligibility (Availity), payer attribution, and service fund payments
• Reviews reports, works queues and recommends improvements to enhance the unit’s productivity and meet goals
• Collaborates with Billing, Credentialing, and Analytics to improve provider-payer roster reconciliation
• Audits current procedures to monitor and improve efficiency of RCM Optimization operations
• Collaborates with stakeholders to support RCM Optimization initiatives including but not limited to payer contestation workflows, including funding disputes and disenrollment recovery
• Ensures that the activities of the RCM Optimization are conducted in a manner that is consistent with overall department policies, and follow any regulatory guidelines and requirements
• Participates in the development and application of operating policies and procedures
• Monitors timelines, process improvements, and system enhancements in support of RCM Optimization goals
• Provides training, support, and troubleshooting for RCM processes and tools as needed
• Performs other duties as assigned to support the RCM optimization strategy

Requirements

• Expertise in RCM operations including billing, eligibility validation, provider credentialing, and claims lifecycle
• Strong written and verbal communication skills and ability to work cross-functionally across departments
• Familiarity with payer systems, clearinghouses (e.g., Availity), and encounter/claim file workflows
• Ability to analyze data and work independently
• Must be able to develop and maintain a professional, service-oriented working relationships with physicians, insurance companies and healthcare providers
• Must be able to understand and comply with policies and procedures
• Knowledge of insurance guidelines, Medicare Advantage, Medicaid and Commercial Payers
• Ability and willingness to travel locally, regionally and/or nationally up to 10% of the time; flexible to work weekends as needed
• Spoken and written fluency in English

Nice-to-haves

• Associate degree in Healthcare or Business Administration preferred or equivalent experience
• Two (2) years’ experience in a healthcare setting preferably Revenue Cycle or Medicare Advantage organization

Benefits

• Great compensation
• Comprehensive benefits
• Career development and advancement opportunities
• Great work-life balance