Revenue Operations & Clean Claim Manager

Job Details Description This position manages revenue operations work queues, establishes clean-claim controls, monitors first-pass acceptance and rejection trends, and coordinates corrective actions when billing or documentation defects to place revenue at risk. The Manager partners closely with Order Management, Revenue Recovery, Payment Integrity & Revenue Performance, Revenue Systems Strategy & Business Optimization, Finance, Payer Relations, Compliance, Information Technology, and external vendors. Core Competencies Revenue Operations Leadership: Leads claim creation, validation, submission readiness, and clean-claim workflows with clear priorities, ownership, service expectations, and accountability for quality, timeliness, and results.Claims, Billing, and Clean-Claim Expertise: Applies strong knowledge of healthcare claims, payer requirements, billing rules, EDI workflows, and timely filing to ensure claims are complete, accurate, compliant, and submission-ready.Quality, Risk, and Work-Queue Management: Maintains disciplined oversight of work queues, aging, quality controls, and escalations to reduce billing defects, protect timely filing, and minimize financial exposure.Root-Cause Analysis and Process Improvement: Identifies recurring defects, rejection patterns, and workflow gaps and partners across teams to implement corrective actions and sustainable process improvements.Data-Driven Decision-Making: Uses operational, quality, productivity, aging, and financial data to identify trends, prioritize work, evaluate performance, and support informed decisions.Cross-Functional Collaboration and Communication: Partners effectively across operational, financial, technical, compliance, and payer-facing teams to resolve issues, strengthen handoffs, and maintain clear accountability.Coaching, Accountability, and Follow-Through: Sets clear expectations and provides consistent coaching, feedback, and development while ensuring performance gaps, commitments, and corrective actions reach resolution. Essential Duties & Responsibilities Revenue Operations Leadership Lead daily revenue operations and clean-claim activities within the assigned scope.Establish work priorities, queue of ownership, service expectations, escalation standards, and quality requirements.Ensure claims are assigned, reviewed, documented, corrected, submitted, and escalated consistently.Monitor staffing capacity, workload distribution, productivity, quality, and turnaround time.Lead employee selection, onboarding, coaching, cross-training, competency development, and performance management. Claim Creation, Validation, and Submission Readiness Oversee claim creation and validation after the appropriate operational handoff and delivery milestone.Confirm required billing data, payer information, codes, modifiers, units, dates, pricing, documentation references, and claim-format requirements are complete and accurate.Apply approved payer and billing rules to determine claim readiness.Prevent incomplete, unsupported, duplicate, or inaccurate claims from entering the submission workflow.Ensure claims are submitted or released within applicable filing requirements and internal turnaround standards. Clean Claim and Billing Quality Management Establish clean-claim review standards and quality control processes.Monitor clean claim rate, first-pass acceptance rate, rejection rate, correction volume, and repeat billing defects.Conduct or oversee targeted quality reviews based on risk, trend, payer, employee, product, code, or workflow.Identify recurring billing defects and coordinate corrective actions with the appropriate business owner.Maintain quality evidence, defect categories, corrective action records, and follow-up validation. Rejection, Exception, and Correction Management Oversee rejected, suspended, returned, documentation-pending, and correction-required claim queues.Define when an item can be corrected within Revenue Operations and when it must be returned to Order Management or another source of owner.Monitor failed or incomplete GenHealth-enabled and NikoHealth-supported transactions.Ensure exceptions include a clear reason, assigned owner, next action, due date, and escalation status.Analyze rejection and exception trends and escalate systemic risks. Work-Queue and Timely Filing Governance Maintain disciplined queue of ownership, aging standards, follow-up expectations, and escalation thresholds.Monitor unbilled, held, rejected, returned, suspended, and unresolved claim activity.Protect timely filing through proactive aging review and escalation.Identify bottlenecks, stalled handoffs, and unresolved documentation dependencies.Provide leadership visibility into claim volume, queue aging, financial exposure, and operational barriers. Cross-Functional Handoffs and Corrective Action Partner with Order Management when missing or inaccurate upstream information affects claim readiness.Provide structured feedback on authorization, documentation, payer, demographic, product, or order defects that create billing risk.Partner with Revenue Recovery on denial and nonpayment trends requiring upstream billing correction.Partner with Payment Integrity & Revenue Performance when financial findings indicate a claim-build, posting, adjustment, or workflow concern.Partner with Revenue Systems Strategy & Business Optimization on business requirements, workflow redesign, SOP standards, UAT, and corrective-action implementation. Revenue Systems Support Provide business requirements and operational subject matter expertise for GenHealth and NikoHealth billing workflows.Participate in UAT, process validation, training, implementation of readiness, and stabilization activities.Monitor automation exceptions, manual rework, output accuracy, and workflow adoption within Revenue Operations.Escalate recurring workflow or configuration concerns to Revenue Systems Strategy & Business Optimization and the Operations Product Owner & Systems Administrator.Maintain clear separation between business workflow ownership and technical system administration. Analytics and Reporting Develop or maintain operational dashboards, queue reports, quality summaries, and clean-claim performance reporting.Analyze claim volume, acceptance, rejection, correction, aging, productivity, and quality trends.Quantify financial exposure associated with billing defects, held claims, untimely action, and unresolved exceptions.Provide accurate, timely, and decision-ready reporting to department leadership.Use performance data to coach employees, prioritize improvement of work, and validate results. Performance Expectations Improve clean claim rate and first-pass acceptance rate.Reduce preventable rejections, corrections, billing defects, and manual rework.Maintain timely claim release and filing compliance.Ensure revenue operations queues are assigned, current, documented, and escalated consistently.Improve claim readiness and reduce unresolved handoff defects.Provide timely and accurate operational reporting.Convert recurring billing findings into sustainable corrective actions. Qualifications Minimum Qualifications Bachelor's degree in healthcare administration, Business Administration, Finance, Operations Management, or a related field, or an equivalent combination of education and directly related experience.Seven or more years of progressive healthcare billing, claims, revenue operations, or revenue cycle experience.Three or more years of supervisory, team-lead, management, or formal cross-functional leadership experience.Demonstrated knowledge of claim creation, billing requirements, corrections, rejections, EDI or clearinghouse workflows, timely filing, and work-queue management.Experience managing productivity, quality, turnaround time, and operational performance.Experience analyzing billing defects and implementing corrective actions.Proficiency with Excel, healthcare billing systems, and operational reporting.Strong communication, prioritization, documentation, and cross-functional leadership skills. Preferred Qualifications DME/HME billing or revenue operations leadership experience.Commercial, Medicare Advantage, Medicaid Managed Care, or multi-payer billing experience.Experience with NikoHealth or a comparable DME/HME or healthcare revenue-cycle platform.Experience supporting GenHealth or another automated claims, quality, or workflow solution.Experience with claim quality, rejection management, process improvement, or system implementation.Lean, Six Sigma, project management, billing, coding, or revenue-cycle certification. Key Performance Indicators Clean claim rate and first-pass acceptance rateRejection, correction, and billing defect ratesUnbilled volume, backlog, and queue agingTimely filing compliance and claim release turnaroundProductivity and work completed per FTEException resolution and corrective-action closureAutomation exception rate, output accuracy, and manual interventionOperational reporting timeliness and dashboard accuracy General Employment Expectations Maintain accurate and timely documentation in NikoHealth and other authorized systems.Follow approved workflows, internal controls, escalation procedures, privacy requirements, and department policies.Meet established productivity, quality, accuracy, timeliness, and financial performance expectations.Protect confidential patient, payer, employee, contract, and financial information.Participate in training, system testing, workflow stabilization, and continuous improvement activities.Collaborate professionally across Order Management, Patient Experience, Revenue Recovery, Payment Integrity, Revenue Systems Strategy, Finance, Payer Relations, Contracting, Compliance, IT, vendors, and other stakeholders.Perform other related duties consistent with the position’s purpose and level of responsibility.