JOB TITLE: RCM Operations Manager (Billing + Credentialing Manager)

JOB SUMMARY

We are seeking an experienced RCM Operations Manager (Billing + Credentialing Manager) to oversee and optimize our end-to-end revenue cycle operations, including medical billing, claims management, denials/rejections, payment posting, patient balances, provider credentialing, and payer enrollment.

This role is responsible for driving revenue performance, ensuring regulatory compliance, maintaining accurate payer relationships, and leading a team to meet productivity and financial targets. The ideal candidate is highly organized, detail-driven, proactive, and comfortable building workflows, managing KPIs, and solving complex payer issues.

KEY RESPONSIBILITIES

Revenue Cycle Management (Billing & Collections)

- Oversee daily operations of billing, claims submission, claim edits, and follow-up.

- Monitor and improve clean claim rate, reduce rejections, and ensure timely submission of claims.

- Manage denial and rejection workflows, including appeals, corrected claims, and payer disputes.

- Ensure accurate payment posting, adjustments, and reconciliation to EOBs/ERAs.

- Oversee patient billing and collections processes (statements, follow-up, payment plans if applicable).

- Collaborate with clinical/front office teams to ensure documentation supports billing requirements.

Credentialing & Payer Enrollment

- Lead provider credentialing and re-credentialing for all payers (Medicare, Medicaid, commercial, networks).

- Manage CAQH profiles, payer applications, EFT/ERA setup, contract participation status, and provider demographic updates.

- Maintain credentialing calendar and ensure renewals are completed prior to expiration.

- Resolve payer enrollment delays and provide regular progress updates to leadership.

Compliance & Risk Management

- Ensure compliance with payer guidelines, billing regulations, HIPAA requirements, and internal policies.

- Support audits (internal/external), correct process issues, and implement corrective action plans.

- Maintain accurate documentation, tracking logs, and workflow SOPs.

Team Leadership & Performance Management

- Supervise billing and credentialing staff (or coordinate vendors) and ensure productivity goals are met.

- Train team members on workflows, payer rules, documentation requirements, and system processes.

- Assign workload, evaluate performance, coach staff, and participate in hiring decisions.

- Create and enforce standardized processes to reduce errors and improve turnaround times.

Reporting & KPI Management

- Track and report key performance indicators (KPIs), including:

- Days in A/R

- Denial rate and denial categories

- Net collection rate / gross collection rate

- First-pass acceptance / clean claim rate

- Charge lag and billing lag

- Credentialing turnaround time

- Prepare weekly/monthly RCM reports and recommend improvements based on data.

- Identify revenue leakage and implement strategies to improve cash flow.

System Optimization & Process Improvement

- Optimize billing system/EHR workflows, payer portals, clearinghouse settings, and automation tools.

- Develop standard operating procedures (SOPs), checklists, and internal controls.

- Lead implementation of improvements to support scalability and efficiency.

REQUIRED QUALIFICATIONS

- 3–5+ years of RCM experience in healthcare billing and revenue cycle operations.

- 2+ years managing credentialing and payer enrollment processes.

- Proven experience managing staff or vendors in an RCM environment.

- Strong working knowledge of:

- Claims submission workflows (electronic and corrected claims)

- Denials management and appeals

- Eligibility verification, benefits, and authorizations (preferred)

- Medicare/Medicaid/commercial payer requirements

- EFT/ERA setup and payer portal management

- Familiarity with EHR/PM systems and clearinghouses.

- Strong organizational skills, attention to detail, and ability to meet deadlines.

PREFERRED QUALIFICATIONS

- Experience in home health, home care, DME, behavioral health, primary care, or multi-specialty clinics.

- Knowledge of CPT/ICD-10/HCPCS, modifiers, and medical necessity guidelines.

- Experience with Medicare/Medicaid revalidations and enrollment requirements.

- Certifications preferred: CPB, CPC, CBCS, or credentialing certification.

- Advanced Excel and reporting skills.

SKILLS & COMPETENCIES

- Strong leadership, accountability, and problem-solving mindset

- Excellent written and verbal communication

- Ability to build workflows and enforce compliance

- Comfortable working in fast-paced environments with multiple priorities

- High attention to detail and strong analytical decision-making

- Strong payer negotiation and follow-up skills

WHAT SUCCESS LOOKS LIKE IN THIS ROLE

- Clean claims submitted on time, with reduced rejections and denials

- Lower A/R days and stronger collections performance

- Credentialing and payer enrollments completed efficiently with proactive follow-up

- Accurate reporting and clear visibility into revenue performance

- A trained, efficient RCM team with structured workflows and SOPs