Product Development
Position Overview
We are seeking a Process Analyst / Subject Matter Expert (SME) to provide deep domain expertise in the full US Healthcare Revenue Cycle Management (RCM) lifecycle, driving process optimization, AI/ML adoption, automation, and operational excellence.
The role spans the entire RCM cycle: Patient Registration → Eligibility & Benefits → Prior Authorization → Coding & Documentation → Charge Capture → Claims Submission → Payment Posting → Denial Management → Collections & Reporting.
The SME will focus on full RCM workflows, payer systems, EHR/EMR/PMS integrations, EDI transactions, coding standards, payer portals, and payer databases (e.g., NCCi, AAPC, AHIMA, AMA), ensuring compliant, scalable, and data-driven RCM operations and supporting analytics, AI/automation, and dashboard/reporting initiatives for US healthcare operations.
The role collaborates with business analysts, data scientists, RPA engineers, AI/ML teams, system/application analysts & developers, and clients to implement AI-driven process improvements.
Job Roles & Responsibilities
End-to-End RCM Process Expertise:
- Analyze and optimize full RCM workflows, including Patient Registration, Eligibility Verification, Prior Authorization, Coding, Charge Capture, Claims Submission, Payment Posting, Denial Management, Collections, and Reporting.
- Map detailed process flows, exceptions, and system interactions for RCM operations.
- Maintain best-practice SOPs aligned with compliance, AI/automation, and system integrations.
- Leverage knowledge of payer databases, payer websites, and industry standards (NCCi, AAPC, AHIMA, AMA) to validate claims and workflows.
- Serve as domain expert across the full RCM cycle:
- Patient Registration & Scheduling
- Eligibility & Benefits Verification
- Prior Authorization
- Medical Coding (ICD-10, CPT, HCPCS)
- Claims Submission & Management
- Denials Management & Collections
- Revenue Reconciliation & Financial Reporting
- Identify process gaps, inefficiencies, and automation opportunities within RCM workflows.
EHR/EMR/PMS & System Expertise:
- Work with EHR/EMR platforms, PMS systems, and integrated billing systems to align business processes with operational and AI workflows.
- Collaborate with System/Application Analysts to ensure workflows translate into functional requirements.
- Validate RPA, AI agents, and automation integrations within healthcare IT systems.
Payer & Market Intelligence
- Maintain expertise on payer systems, portals, and clearinghouses:
- Commercial payers: UnitedHealthcare, Anthem, Aetna, Cigna, Humana, Blue Cross/Blue Shield
- Government payers: Medicare, Medicaid
- Clearinghouses: Availity, Change Healthcare, Optum, RelayHealth, Trizetto
- Conduct market research on payer rules, reimbursement policies, adjudication workflows, and claims lifecycle.
- Maintain knowledge of professional coding & billing standards: AAPC, AHIMA, AMA CPT, ICD-10, HCPCS, NCCI edits.
AI/ML & Automation Enablement:
- Identify opportunities for AI/ML, GenAI, LLM-based agents, and Agentic AI in RCM workflows.
- Partner with data scientists and RPA engineers to operationalize predictive models, agentic AI, and automated decision-making.
- Support multi-agent orchestration, workflow automation, and analytics-driven process improvements.
Training, Mentorship & Knowledge Transfer:
- Serve as domain authority for cross-functional teams including AI, RPA, system analysts, and client stakeholders.
- Conduct training sessions, workshops, and knowledge transfer for RCM systems, AI workflows, and compliance processes.
- Develop process manuals, SOPs, and training materials integrating full RCM cycle knowledge with AI/automation best practices.
Technical Collaboration:
- Collaborate with Product, Engineering, Data, AI/ML, RPA, and DevOps teams to translate business and process requirements into technical solutions.
- Support design and validation of end-to-end RCM tools, including workflow automation, AI/GenAI models, and multi-agent orchestration.
- Work closely with data scientists, AI/ML engineers, cloud architects, RPA developers, and DevOps teams to ensure business requirements are translated into scalable, compliant solutions.
- Support LLM Ops, MLOps, and Agentic AI deployment by defining input/output requirements, monitoring KPIs, and validating results.
- Assist in integration of AI predictions and autonomous agent outputs into RCM and cloud workflows.
Analytics, Reporting & Insights:
- Define KPIs, dashboards, and reporting frameworks for operational, financial, and compliance performance.
- Collaborate with data and analytics teams to ensure data accuracy, integrity, and actionable insights.
- Conduct deep analysis of RCM projects, identifying trends, bottlenecks, and revenue optimization opportunities.
Compliance & Governance:
- Ensure adherence to HIPAA, SOC 2, GDPR, and internal healthcare compliance standards.
- Maintain audit-ready documentation for AI/ML models, RPA workflows, and process changes.
- Implement data governance and process validation frameworks for operational reliability.
Stakeholder Management:
- Serve as the liaison between technical teams, product owners, and business stakeholders.
- Facilitate workshops, requirement reviews, and solution validation sessions.
Candidate Requirements
- Bachelor’s or Master’s degree in Healthcare Administration, Health IT, Business Analysis, or related field.
- 7–12+ years in US Healthcare RCM, with hands-on experience across full-cycle processes.
- Strong knowledge of payer systems, EHR/EMR, PMS, clearinghouses, and EDI standards.
- Experience collaborating with technical teams to design automated, AI-enabled, and analytics-driven RCM workflows.
- Proven understanding of coding, billing, claims adjudication, and healthcare compliance.
Technical Expertise:
- EHR/EMR & PMS: Epic, Cerner, Allscripts, Meditech, AthenaHealth, NextGen
- Payer Portals & Clearinghouses: Availity, Change Healthcare, Optum, RelayHealth, Trizetto
- EDI Standards: X12 837 (claims), 835 (remittance), 270/271 (eligibility), 276/277 (claim status), 278 (prior authorization)
- Coding & Compliance: ICD-10, CPT, HCPCS, NCCI edits, AAPC, AHIMA, AMA CPT
- Analytics & Reporting: SQL, Snowflake, Redshift, Tableau, Power BI
- AI & Automation Collaboration: Guide LLM Ops, Agentic AI, GenAI, and RPA workflow integration
Skillset:
- Deep understanding of end-to-end US RCM processes and payer ecosystems.
- Ability to analyze, document, and optimize complex workflows for automation and AI integration.
- Expertise in EDI transactions, payer rules, and coding compliance.
- Strong analytical, problem-solving, and reporting skills.
- Excellent communication, stakeholder management, and knowledge transfer skills.
- Experience in cross-functional collaboration with technical and operational teams.
- Ability to translate complex technical workflows into actionable business insights.
- Understanding in AI/ML, RPA, Agentic AI, and healthcare operations.
- Knowledge of compliance, governance, and audit standards.
- Ability to drive cross-functional collaboration and solution adoption.
Strategic Impact:
- Ensure comprehensive RCM process coverage across all modules and systems.
- Enable AI/automation adoption by providing domain and workflow expertise.
- Reduce process inefficiencies and claim denials, improving revenue and compliance.
- Bridge business operations and technical development for scalable RCM solutions.
Kindly Note: At Credence, we uphold the highest standards of integrity in our recruitment process. We do not charge any fees at any stage of the hiring process, and we strictly prohibit any third parties, vendors, or individuals from soliciting money in exchange for job opportunities at Credence.
If you are approached by anyone requesting payment or offering you a position at Credence in exchange for money, do not engage with them. Such actions are fraudulent and not authorized by Credence. Please report any such incidents immediately to our official HR team at [email protected]m
Your safety and trust are important to us. Thank you for helping us maintain a fair and transparent hiring environment.