01Role Overview
The AGM/GM - Quality Analyst (RCM Healthcare) will lead and manage the Quality Assurance function across end-to-end Revenue Cycle Management (RCM) operations. The role is responsible for defining quality frameworks, ensuring compliance with regulatory standards, driving continuous improvement initiatives, and leading a high-performing QA team to deliver accuracy, efficiency, and superior service quality across billing, claims, AR, denials, and collections.
02Key Responsibilities
Quality Framework & Governance:- Design, implement, and manage a comprehensive QA framework for all RCM operations including billing, claims processing, AR follow-up, denials, appeals, and collections.- Define, standardize, and enforce QA standards, audit methodologies, evaluation metrics, and quality benchmarks.- Ensure adherence to internal SOPs, client SLAs, payer guidelines, and regulatory/compliance requirements.Audit & Compliance:- Plan and execute regular, periodic, and ad-hoc quality audits across RCM workflows.- Monitor accuracy, compliance, productivity, and SLA adherence through structured audits and reviews.- Identify process gaps and compliance risks and recommend corrective actions. Root Cause Analysis & Improvement:- Conduct root cause analysis (RCA) for quality issues such as billing errors, claim rejections, denial trends, and rework.- Drive corrective and preventive action (CAPA) plans in collaboration with operations and training teams.- Lead continuous improvement initiatives to reduce errors, denials, and turnaround times. Process Documentation & SOPs:- Develop, review, and update SOPs, QA manuals, workflows, audit checklists, and quality documentation.- Ensure documentation aligns with evolving payer rules, regulatory changes, and client requirements.- Reporting & Management Communication- Prepare and present quality dashboards, MIS, and performance reports for senior management.- Track and report metrics such as error rates, first-pass yield, denial trends, audit scores, and improvement outcomes.- Provide actionable insights and recommendations based on data trends.Team Leadership & Capability Building:- Lead, mentor, and manage a team of QA professionals across RCM functions.- Conduct calibration sessions, performance reviews, and feedback cycles to ensure scoring consistency.- Identify training needs and support skill development initiatives in collaboration with L&D teams.Skills & Qualifications:- Strong expertise in US Healthcare RCM processes: billing, coding interface, claims, AR, denials, and collections.- Proven experience in QA frameworks, audit models, RCA, and CAPA within RCM operations.- Strong analytical skills with experience in quality metrics, dashboards, and MIS reporting.- Leadership experience managing large QA teams and cross-functional stakeholders.- Excellent communication, stakeholder management, and presentation skills.Preferred Background:- Extensive experience in Healthcare RCM Quality Management roles.- Exposure to multi-client environments and large-scale operations is an advantage.- Prior experience in senior QA leadership roles (AGM/GM level preferred). .
