Senior Business Analyst - RCM
- Citiustech
- 6 - 15 years
- Pune
- 6 days ago
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Job Description
Role Summary
As a Senior Healthcare RCM SME, you will collaborate within Agile teams to design and enhance AI focused healthcare RCM solutions. The role emphasizes leveraging domain expertise in AR and Denial Management and other RCM areas to identify optimization opportunities and implement innovative solutions using AI/ML and other digital technologies.
Key Responsibilities
- Analyze and optimize RCM workflows, including AR and denial management, to improve efficiency and reduce costs.
- Identify and define high-impact use cases for AI-driven denial prediction and automation.
- Translate domain knowledge (PB/HB, coding, edits, payer rules) into model-ready features for denial prediction
- Drive continuous improvement through problem-solving and strategic thinking.
- Assist developers/data scientists in selecting high-signal features, labels, and targets; validate feature importance with business context.
- Define ground-truth labeling for denials (CARC/RARC codes, payer-specific edits)
- Perform root cause analysis for denials; recommend interventions (front-end edits, coding corrections, documentation improvements).
- Consolidate and interpret regulatory updates (Medicare/Medicaid, payer bulletins, HFMA guidance), and translate into concrete AI features/rules.
- Maintain expertise in LCD (Local Coverage Determinations), NCD (National Coverage Determinations), LMRP (Local Medical Review Policies), ICD-10-CM, CPT/HCPCS, modifiers, medical necessity, prior authorization, and coverage policies.
- Oversee data validity, accuracy, consistency across EDI 837/835, eligibility (270/271), and remittance datasets; define data controls.
- Coordinate strategic flow of business intelligence data to users; answer data questions for clients and leadership.
- Conduct competitor and industry trend analysis to inform strategic decisions.
- Lead client engagements, ensuring customer success and building strong relationships.
Required Skills
- Comprehensive knowledge of RCM processespatient access, prior authorization, medical coding, benefit verification, payment reconciliation, appeals, and denial management.
- End-to-end knowledge on AR workflows (worklists, follow-ups, appeals) for HB & PB; identify points of leakage, rework, and automation opportunities.
- Coding & Compliance: Strong knowledge of LCD/NCD/LMRP, ICD-10-CM, CPT/HCPCS, modifiers, medical necessity, payer-specific policies, and audit requirements.
- Data & AI Readiness: Hands-on with EDI datasets (837/835/270/271), EHR (Epic/Cerner/Allscripts/eClinicalWorks/McKesson), and analytics/BI tools; able to translate business rules into features and pre-submission scrubs.
- Analytics Mindset: Skilled in data analysis, trend detection, hypothesis testing, and KPI measurement (first-pass yield, denial rate, Days in AR, cash acceleration, DNFB/DNFC).
- Communication: Excellent stakeholder management; ability to explain technical concepts in clear business terms; strong client-facing skills.
- Digital Technologies: Understanding of AI/ML, analytics, GenAI, and automation for healthcare use cases.
Job Classification
Industry: IT Services & ConsultingFunctional Area / Department: Data Science & AnalyticsRole Category: Business Intelligence & AnalyticsRole: Business AnalystEmployement Type: Full timeContact Details:
Company: CitiustechLocation(s): Pune
Keyskills: Requirement Gathering User Stories RCM Business Analysis Revenue Cycle Management Claims AR Calling US Healthcare Accounts Receivable Denials Denial Management Ar Billing
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Citiustech
Company Website: https://www.citiustech.com/aboutusCitiusTech is a specialist provider of healthcare technology services and solutions to healthcare technology companies, providers, payers and life sciences organizations. With over 4,500+ professionals worldwide, CitiusTech enable...
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