Director Revenue Cycle

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Develop and execute the revenue cycle improvement plan. Establish priorities, measurable goals, staffing requirements and performance standards in collaboration with the CFO.
• Partner with Operations to improve registration, insurance verification, eligibility, coordination of benefits, authorizations and patient financial counseling. Support consistent implementation of the sliding fee discount program and patient collection policies.
• Ensure complete and timely capture of billable encounters and services. Oversee coding quality, documentation feedback, charge entry, modifiers, rate codes and payer-specific requirements in collaboration with qualified coding and clinical staff.
• Oversee claim edits, clearinghouse acceptance, rejections, timely filing and work queues. Maintain controls that identify unbilled encounters and resolve claim errors before revenue is lost.
• Lead a structured denial management program that identifies causes, assigns corrective actions, tracks appeals and measures recovery. Resolve recurring issues through staff training, workflow changes and payer escalation.
• Establish follow-up standards by payer, age and value. Monitor aged and high-dollar balances, underpayments, recoupments and unresolved claims; ensure timely resolution and appropriate escalation.
• Ensure accurate and timely posting of ERAs, EFTs, checks and adjustments. Maintain controls over unapplied cash, credit balances, refunds and write-offs, including documented approvals and segregation of duties.
• Oversee applicable New York Medicaid, Medicaid managed care, Medicare FQHC and commercial payer billing. Manage PPS-related and supplemental/wrap payment workflows and support MCVR submissions and reconciliation with Finance, including supporting encounter data and payment validation.
• Reconcile revenue cycle activity with Finance, including patient revenue, cash, adjustments, receivables and general ledger balances. Support month-end close, audits, cash forecasts and analysis of contractual allowances, bad debt and write-offs.
• Lead escalations for systemic denials, underpayments, enrollment issues and payment delays. Collaborate with the CFO on payer reimbursement analysis and maintain current billing guidance and escalation contacts.
• Coordinate provider and site enrollment with Credentialing, monitor effective dates and payer participation, and identify billing restrictions and revenue risks before claims are submitted.
• Serve as business owner for revenue cycle functions within eClinicalWorks and related clearinghouse and payer technologies. Partner with Informatics to maintain billing rules, rate codes, edits, interfaces, work queues and reporting; test changes and monitor results.
• Partner with Compliance to maintain billing and coding policies, audit readiness and corrective action plans. Monitor applicable federal, state, FQHC and payer requirements; escalate suspected billing errors or overpayments promptly.
• Recruit, coach and evaluate staff; allocate work, establish productivity and quality standards, provide cross-training and develop succession coverage. Manage departmental resources and vendors within approved budgets.
• Lead cross-functional initiatives to prevent revenue leakage, improve patient experience and prepare billing workflows for new providers, services and sites. Perform other related duties as assigned.
• Develop a monthly dashboard for the CFO and senior leadership, with interim updates on material risks and cash collection issues. Establish consistent definitions, reliable data sources and approved targets; report trends, root causes, responsible owners and corrective actions.
• Cash collections, gross charges, net collection rate and payer mix.
• AR days, balances over 90 and 120 days, high-dollar claims and payer-specific aging.
• Clean claim rate, first-pass acceptance and resolution, denial rate, denial overturn rate and leading denial categories.
• Charge lag, unbilled encounters, payment-posting lag and unapplied cash.
• Credit balances, refunds, write-offs, bad debt and supplemental/wrap payment status.