Revenue Cycle Manager

We are seeking a healthcare professional with a strong medical background to support Fraud, Waste & Abuse (FWA) detection, clinical audit, and Revenue Cycle Management (RCM) activities. The role focuses on identifying billing irregularities, ensuring clinical and coding compliance, optimizing reimbursement, and reducing financial leakage while maintaining regulatory and ethical standards.

Key Responsibilities

Fraud, Waste & Abuse (FWA)

• Identify, investigate, and analyze potential fraud, waste, and abuse related to medical billing, coding, and clinical documentation
• Conduct pre-payment and post-payment reviews of claims to detect inappropriate utilization or billing patterns
• Collaborate with internal teams and external stakeholders to resolve FWA cases and recommend corrective actions
• Prepare detailed FWA investigation reports, findings, and root cause analysis
• Support implementation of FWA prevention controls and compliance initiatives

Audit & Compliance

• Perform clinical and coding audits (IP, OP, ER, Daycare, Pharmacy, Procedures)
• Validate compliance with payer contracts, medical necessity guidelines, and regulatory standards
• Review medical records to ensure accuracy of ICD-10, CPT, HCPCS, DRG, and modifier usage
• Identify documentation gaps and recommend improvements to providers and coding teams
• Support internal, external, and regulatory audits

Revenue Cycle Management (RCM)

• Review end-to-end RCM processes, including charge capture, coding, billing, and reimbursement
• Analyze denials, underpayments, and revenue leakage trends
• Work closely with billing and coding teams to optimize reimbursement and reduce denials
• Support payer negotiations and contract compliance reviews
• Ensure adherence to turnaround times, accuracy benchmarks, and KPIs

Required Qualifications

Education

• Medical background required, such as:
• MBBS / MD / BDS / BAMS / BHMS
• B.Sc. Nursing / Allied Health Sciences
• Additional certification in Medical Coding, Auditing, or Compliance is preferred

Experience

• 3–8+ years of experience in FWA, Medical Audit, or RCM
• Strong exposure to health insurance, TPA, hospital, or payer environment
• Hands-on experience reviewing medical records and claims

Skills & Competencies

• Strong knowledge of clinical workflows, medical necessity, and treatment protocols
• Proficiency in ICD-10, CPT, HCPCS, DRG, and payer guidelines
• Analytical skills with the ability to detect abnormal billing patterns
• Excellent documentation, reporting, and communication skills
• High ethical standards and attention to detail

Preferred Certifications (Optional)

• Certified Professional Medical Auditor (CPMA)
• Certified Professional Coder (CPC / CCS)
• Certified in Healthcare Compliance (CHC)
• CFE (Certified Fraud Examiner) – advantage

Key Attributes

• Strong clinical judgment
• Investigative mindset
• Detail-oriented and compliance-focused
• Ability to work independently and cross-functionally