Operations Program Manager

This is a fully remote position, open to applicants in United States.

📋 Description

• Create and implement the strategic roadmap for clinical denial management initiatives.

• Set program objectives, key performance indicators (KPIs), governance frameworks, and performance benchmarks.

• Supervise various teams, managers, and/or client programs.

• Align the clinical denial strategy with the organization's revenue cycle goals.

• Develop standardized operating models, workflows, and best practices.

• Take ownership of program-level denial recovery and financial outcomes.

• Track gross and net revenue opportunities, at-risk dollars, recovery rates, overturn rates, and denial inventories.

• Formulate strategies to enhance reimbursement and minimize revenue loss.

• Assist in financial forecasting, business case development, and resource planning.

• Identify automation, technology, and workflow optimization opportunities.

• Provide expertise in complex clinical denial categories.

• Establish comprehensive strategies for medical necessity, DRG, level-of-care, clinical validation, documentation, and payer-specific denials.

• Analyze emerging payer policies and reimbursement updates.

• Develop strategies for addressing high-value and systemic denial challenges.

• Collaborate with clinical and revenue cycle leadership to pinpoint root causes.

• Act as the senior operational contact for designated clients and programs.

• Lead executive-level business reviews and performance discussions.

• Present program performance metrics, financial results, trends, risks, and strategic recommendations.

• Manage client expectations and handle escalations effectively.

• Identify opportunities for program growth and additional value creation.

• Spearhead enterprise-wide denial prevention initiatives.

• Utilize data analytics to uncover systemic denial drivers.

• Partner with CDI, HIM, coding, utilization management, clinical operations, finance, and billing leadership.

• Develop corrective action and prevention strategies.

• Assess the financial and operational impacts of prevention initiatives.

• Lead transformation projects that involve technology, analytics, automation, and workflow redesign.

• Provide leadership to Managers, Team Leads, and clinical denial professionals, overseeing a team of at least 50.

• Establish strategies for leadership development and succession planning.

• Foster a culture of accountability, continuous improvement, and client service.

• Ensure adequate staffing models and organizational structures.

• Oversee competency and training initiatives.

• Ensure that programs comply with regulatory requirements, payer policies, contractual obligations, and organizational standards.

• Monitor emerging regulatory and reimbursement developments.

• Identify operational and financial risks and create mitigation strategies.

⛳️ Requirements

• Bachelor’s degree in Nursing, Healthcare Administration, Health Information Management, or a related field.

• Active RN license or relevant clinical credential.

• Over 7 years of healthcare experience, including significant involvement in clinical denials, CDI, RCM, utilization management, appeals, or reimbursement.

• A minimum of 3 years of progressive leadership or management experience.

• Proven experience in managing large-scale programs, multiple teams, or complex client engagements.

• Strong knowledge of inpatient DRG, medical necessity, level of care, clinical validation, coding, reimbursement, and payer policies.

• Demonstrated financial and analytical skills.

• Excellent communication, presentation, negotiation, and stakeholder management abilities at an executive level.

• Preferred: CDAS or an equivalent denial management credential.

• Preferred: CCDS/CDIP or an equivalent CDI certification.

• Preferred: Master’s degree such as MHA, MBA, MSN, or a related discipline.

• Preferred: Experience with enterprise RCM transformation.

• Preferred: Familiarity with Epic, payer portals, denial analytics, and business intelligence platforms.

• Preferred: Experience managing programs across multiple hospitals or clients.

• Preferred: Background in automation, AI, analytics, or technology-enabled denial management.

🏝️ Benefits

• Competitive salary.

• Opportunity to influence the HR function of a rapidly expanding BPO.

• Collaborate with a team of industry leaders who have successfully scaled BPOs in the past.

• Opportunities for career growth and professional development.