Principal Clinician – Revenue Cycle Management, RCM

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

📋 Description

• Take ownership of the complete clinical revenue cycle quality for all Penguin AI agents, focusing on documentation integrity, coding accuracy, sampling, and remediation.

• Develop and manage clinical documentation improvement and coding accuracy initiatives.

• Establish inter-rater reliability between AI and human coders/reviewers while identifying drift, bias, and edge cases.

• Implement CMS, payer, and coding standards in collaboration with Compliance.

• Manage denials, including conducting root-cause analyses, formulating appeals strategies, and applying CAPA and closed-loop learning.

• Design clinical training and competency frameworks for coding and CDI reviewers.

• Define clinical and financial metrics, collaborate with Data/Engineering to instrument Snowflake, and provide dashboards and customer reports.

• Generate customer-facing RCM performance reports, revenue integrity scorecards, and quarterly business reviews.

• Extract insights on risk-adjustment and reimbursement optimization from HCC and coding activities.

• Collaborate with teams across Product, Engineering, Customer Success, Finance, and the CMO.

• Represent Penguin AI at customer and payer/regulator forums as well as during conference presentations.

• Develop a scalable clinical RCM quality program, enhance denial and clean-claim/risk-adjustment outcomes, influence product roadmap and policy, and recruit and nurture initial team members.

⛳️ Requirements

• Over 10 years of progressive clinical experience.

• At least 5 years concentrating on revenue cycle management, clinical documentation integrity, coding, or health-plan/health-system reimbursement.

• Proven leadership in RCM or coding accuracy initiatives at scale, encompassing denials management, CDI, audits, and regulatory compliance.

• Proficient understanding of ICD-10, CPT, HCC/risk-adjustment coding, and CMS UM/reimbursement standards, including CMS-0057-F, NCQA, URAC, and HEDIS.

• Capability to interpret queries and evaluate metric definitions such as clean claim rate, denial rate, and A/R days.

• Skill in partnering with analytics, finance, and engineering teams.

• Exceptional written and oral communication skills suitable for clinicians, coders, engineers, and executive stakeholders.

• Active and unrestricted US RN license or equivalent clinical licensure.

• BSN is required.

• MSN, MHA, MBA, or MPH is highly preferred.

• Certification as a Revenue Cycle Representative (CRCR), CCS, CPC, or CDI credential (CCDS/CDIP) is advantageous.

• Familiarity with Snowflake, Looker, Tableau, Epic/Cerner billing modules, or similar tools is a plus.

• Experience in preparing for or maintaining URAC/NCQA/HITRUST accreditations is beneficial.

🏝️ Benefits

• Competitive salary.

• Medical, vision, and dental insurance.

• Generous vacation policy and company holidays.

• A front-row opportunity in one of the most exciting AI companies in healthcare.