Position Summary
The Director – RCM Operations is responsible for the overall financial, operational, and client performance of assigned Orthopedic and Rheumatology practices.
The role provides leadership across the complete revenue cycle, including Coding, Charge Capture, Prior Authorization, Claims, AR, Denials, Payment Posting, DME, Therapy, Infusion/Injection services, Enrollment, Workers’ Compensation, and Patient Accounts.
The Director will serve as a senior client-facing leader, driving collections, reducing aged AR and denials, identifying revenue leakage, improving payer reimbursement, and ensuring achievement of client KPIs.
Key Responsibilities
- Own the overall RCM and financial performance of assigned Orthopedic and Rheumatology clients.
- Lead client meetings, performance reviews, and operational escalations with physicians, administrators, and client leadership.
- Monitor key KPIs including Days in AR, 90+/120+ AR, collections, denial rate, clean claim rate, charge lag, coding TAT, authorization performance, and high-dollar AR.
- Develop strategies to improve collections and reduce aged AR, denials, and revenue leakage.
- Oversee surgical and office billing, fracture care, injections, DME, Physical/Occupational Therapy, Workers’ Compensation, and high-dollar surgical claims for Orthopedic practices.
- Oversee infusion/injection billing, biologics, drug authorization, J-code billing, medical necessity, and high-cost medication reimbursement for Rheumatology practices.
- Partner with Coding teams on issues involving global surgery, modifiers, NCCI/MUE edits, multiple procedures, assistant surgery, drug units, wastage, and documentation requirements.
- Drive prevention of authorization, coding, enrollment, medical necessity, bundling, timely filing, and payer-specific denials.
- Analyze payer reimbursement and identify underpayments, recurring payer issues, and reimbursement opportunities.
- Ensure timely resolution of high-dollar and complex claims.
- Lead Managers, Deputies, Team Leads, and operational teams and establish clear accountability for client performance.
- Partner with Coding, PA, Enrollment, Payment Posting, DME, Therapy, Technology, Analytics, and Client Success teams.
- Drive process improvement and automation initiatives to improve productivity, quality, and collections.
- Support new client implementations, system transitions, and operational stabilization.
Specialty Knowledge
Orthopedics: Strong understanding of surgical billing, fracture care, spine, joint replacement, sports medicine, foot & ankle, hand procedures, injections, DME, Therapy, Workers’ Compensation, global surgery, and surgical modifiers.
Rheumatology: Understanding of office E&M, infusion and injection services, biologics, J-codes, drug units, prior authorization, medical necessity, drug reimbursement, and payer-specific specialty medication requirements.
Software / EHR / PMS Knowledge
Experience with healthcare EHR, PMS, and RCM platforms, preferably:
- ModMed (Modernizing Medicine)
- Epic
- NextGen
- athenahealth (Athena)
- eClinicalWorks (eCW)
- Tebra
- Cerner
