Manager- RCM Application DM Healthcare LLC

1. Business Process & Operations

• Map and design the end‑to‑end RCM process from patient registration to final payment (self‑pay and insurance).

• Analyze current‑state workflows (front desk, clinical, coding, billing, insurance) and define optimized future‑state processes in TrakCare.

• Identify revenue leakage points (e.g., missed/late charges, registration errors, authorization gaps) and drive corrective actions.

• Work closely with registration, nursing, clinicians, coding, billing, and finance teams to embed standard RCM practices in daily operations.

2. Core RCM & Billing

• Ensure accurate charge capture, charge posting, coding, and claim generation across OPD, IPD, ER, day care, and packages.

• Support configuration and use of DRG‑based billing, fee‑for‑service, and package/episode billing models.

• Collaborate with clinicians and coders to improve documentation quality to support compliant coding and maximum legitimate reimbursement.

• Define and monitor key RCM KPIs (clean claim rate, denial rate, unbilled encounters).

3. Saudi Regulations & NPHIES

• Act as the RCM focal point for NPHIES‑related workflows (eligibility, prior authorization, claims, remittance).

• Translate NPHIES and CHI requirements into practical HIS configuration and workflow steps.

• Monitor and manage NPHIES rejections; drive root‑cause analysis and process changes to reduce recurring issues.

• Ensure adherence to local regulatory standards, timelines, and data set requirements for claims and approvals.

4. Insurance Contracts & Pricing

• Work with finance and contracting teams to configure payer contracts in TrakCare (tariffs, service prices, DRGs, packages, discounts).

• Maintain multiple price lists per payer and ensure correct linking to plans, networks, and service types.

• Configure and validate rules for exclusions, caps, deductibles, co‑payments, and maximum benefit limits.

• Support testing of contract configurations using sample claims before go‑live and during contract changes.

5. Technical & Integration Collaboration

• Work closely with IT, vendors, and InterSystems teams to ensure TrakCare RCM modules are correctly configured and integrated.

• Validate data flows from registration and clinical modules to billing, insurance, and external systems (e.g., NPHIES, ERP, payer portals).

• Participate in interface and integration testing (e.g., FHIR, HL7, APIs, batch/flat file claims) and support troubleshooting of data mismatches.

• Provide business input on RCM‑related change requests, enhancements, and issue resolutions.