Job Summary:
The Insurance & RCM Director is responsible for the strategic and operational management of all relationships, contracts, and agreements with medical insurance companies. This role aims to maximize revenue, expand the center’s payer network, and optimize the Revenue Cycle Management (RCM) process. The director will oversee medical approvals, claims, and rejection, while analyzing rejection root causes (medical or technical) to maximize acceptance rates and drive annual revenue growth in alignment with the Center’s financial goals.
Key Responsibilities:
Contract Management & Strategic Partnerships:
- Policy Review & Optimization: Regularly review and evaluate current insurance policies to protect the Center’s financial interests and secure optimal reimbursement rates.
- Network Expansion: Identify, negotiate, review and establish new contracts and agreements with medical insurance companies and third-party administrators (TPAs) not currently in the network.
- Relationship Management: Build and maintain strong, long-term strategic relationships with key stakeholders at insurance firms to secure competitive pricing and favorable terms.
Operational Management (Claims & Approvals):
- Approvals & Claims Supervision: Oversee the end-to-end workflow of medical approval requests and ensure accurate, timely submission of financial claims to payers.
- Rejection Management: Analyze the root causes of medical and technical rejections and implement corrective action plans to minimize rejection and steadily increase the "Approval Rate."
- Financial Reconciliation: Follow up on collections, settlements, and aging accounts receivable with insurance companies to resolve discrepancies and accelerate cash flow.
Financial Analysis & Revenue Growth:
- Revenue & Profitability Analysis: Analyze the revenue share and financial performance of each insurance provider to identify high-yield versus low-performing payers.
- Annual Growth Targets: Develop and execute strategic pricing and negotiation tactics to ensure sustainable annual revenue growth from insurance channels.
- RCM Cross-Functional Collaboration: Coordinate closely with clinical and ancillary departments (Physicians, Nursing, Pharmacy) to improve medical documentation and data quality, directly accelerating the revenue cycle and eliminating revenue leakage.
Reporting:
- Periodic Reporting: Prepare and present comprehensive performance reports (weekly/monthly/quarterly) to executive management, highlighting RCM efficiency, rejection/approval metrics, payer-specific growth, and strategic recommendations.
Job Requirements & Qualifications:
- Bachelor’s degree in medicine & surgery, Pharmacy, Healthcare Management, or a related field. A Master’s degree (MBA/MHA) or professional certification in health insurance/RCM is highly preferred.
- Experience: Minimum of 5 to 7 years of progressive experience in medical insurance management within a major hospital or specialized medical center. Prior experience in oncology or chronic disease centers is a significant advantage.
- Negotiation Skills: Proven track record of successfully negotiating high-value medical contracts and securing profitable terms for healthcare providers.
- Analytical Skills: Advanced capability in financial data analysis, utilizing key performance indicators (KPIs) to drive operational decisions.
- Regulatory Knowledge: Deep understanding of local health insurance laws, regulations (e.g., Council of Health Insurance - CHI rules), and medical coding standards (such as ICD-10-AM).
- Strong leadership, communication, and interpersonal skills to bridge the gap between clinical teams and insurance corporations.
- Full professional proficiency in both Arabic and English (written and spoken).
- Advanced proficiency in Hospital Information Systems (HIS) and data analysis tools (such as advanced MS Excel or BI tools).