RCM Quality and Outcome Improvement Analyst

The RCM Quality and Outcome Improvement Analyst is a key position within the Modmed India Operations. Analysts will be assigned to a group of practices under one or multiple specialties reporting to a specialty lead. While they are responsible for working on claims escalated by practice or Global Partners, an Analyst is responsible for observing and analyzing the gaps/ trends and identifying opportunities to improve the process efficiency which will enhance the overall outcome for new and established customers.

Your Role:

• Play a critical role in meeting productivity targets, delivering a high level of customer service, and ensuring ModMed’s overall service delivery is consistently maintained at the highest standards while ensuring ModMed’s billing and compliance processes and Standard Operating Procedures (SOPs) are followed.
• Responsible for identifying and addressing opportunities to improve workflows and reduce non-meaningful touches by analyzing trends on inflows of claim-level assignments.
• Set up and manage online portals following the requirements and payer details provided by global partners, including, but not limited to, creating W9 forms and following up with payers.
• Work claims escalated from global partners, practices and onshore teams as per Standard Operating Procedures. (SOPs). Including but not limited to:
  • Analyze claims addressed for credentialing issues from global partners and work closely with onshore to resolve credentialing issues.
  • Review claims assigned to practice for quality and determine if decision tree enhancements will prevent future escalation of a similar claim.
  • Analyze Dashboards/Reports for production and AR trends to identify quality issues; sample the claims and fill out Quality Analysis forms.
• Run reports regularly and maintain a status tracker to keep a close eye on various inventories to ensure global partners are working on the claims timely.
• Closely review the Practice Instructions (client specific requirements) and bring any opportunities to enhance and update to onshore RCM Client Advisors.
• Review KPIs and other important matrix data to ensure the allocated practices are green and have an “A” on the health scorecard.
• Review Jira tickets created by RCM Client Advisors and global partners for timely resolution; analyze ticket trends to recommend fixes to reduce ticket traffic.
• Present and review trends, issues and observations with RCM Client Advisors and join respective practice and vertical calls when appropriate.
• Analyze all functions of practice escalations and contribute to the plans of action shared by global partners and ensure any concerns to meet the plan are addressed.
• Regularly review SOPs to ensure workflows are being followed as documented and any new opportunity is identified where workflows can be improved.
• Work closely on new implementations to identify knowledge transfer challenges and audit the work before it is released.
• Assist in monitoring of Service Legal Agreements (SLA) by our global partners as well as internal teams.
• Perform additional projects and job duties as assigned.

Skills & Requirements:

• 5+ years of related working experience in core Provider RCM out of which minimum 2 years as SME, Asst. Team Lead, Team Lead , QA, QA Lead, etc. within a professional setting.
• Strong understanding of RCM Processes and best practices - knowledge at a transaction level is required.
• Experience working on process improvements/ six sigma quality projects preferred.
• Proven expertise in the front-end and back-end functions of the provider side of US Healthcare RCM such as charges, payment posting , AR follow ups, denials, eligibility, etc.
• Comprehensive understanding of the full revenue cycle process for claim submission, medical insurance policies, and ICD-10 and CPT coding guidelines.
• Proven knowledge of various insurance carriers, including Medicare, private HMOs, PPOs, Capitation and Workers’ Comp.
• Advanced excel skills such as the ability to use formulas to analyze data, create and format pivot tables and templates, use and conditional formatting and validation functions, able to create visualizations of data through charts, graphs and powerpoints; able to manage information located in multiple software systems.
• Exceptional written, verbal and interpersonal communication skills required.
• Committed to developing expertise in respective ModMed products (PM or gPM) within 3 months of employment.
• Professional demeanor, team player, strong time management skills required.
• Able to work during US night shifts within a hybrid work model from home and office is required - this position requires working closely with onshore/offshore teams, as well as with payer reps.