Operations Program Manager
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Job Description
Operations Program Manager leading clinical denial management, revenue recovery, and enterprise transformation programs. Outsourcey connects businesses with dedicated full-time teams in the Philippines.
Responsibilities:
- Develop and execute the strategic roadmap for clinical denial management programs
- Establish program goals, KPIs, governance structures, and performance standards
- Oversee multiple teams, managers, and/or client programs
- Align clinical denial strategy with organizational revenue cycle objectives
- Develop standardized operating models, workflows, and best practices
- Own program-level denial recovery and financial performance
- Monitor gross and net revenue opportunity, dollars at risk, recovery rate, overturn rate, and denial inventory
- Develop strategies to maximize reimbursement and reduce revenue leakage
- Support financial forecasting, business cases, and resource planning
- Identify opportunities for automation, technology, and workflow optimization
- Provide subject-matter leadership for complex clinical denial categories
- Establish enterprise strategies for medical necessity, DRG, level-of-care, clinical validation, documentation, and payer-specific denials
- Review emerging payer policies and reimbursement changes
- Develop strategies for high-value and systemic denial issues
- Partner with clinical and revenue cycle leadership to address root causes
- Serve as senior operational contact for assigned clients and programs
- Lead executive-level business reviews and performance discussions
- Present program performance, financial outcomes, trends, risks, and strategic recommendations
- Manage client expectations and escalations
- Identify opportunities for program expansion and additional value creation
- Lead enterprise-wide denial prevention initiatives
- Use data analytics to identify systemic denial drivers
- Partner with CDI, HIM, coding, utilization management, clinical operations, finance, and billing leadership
- Develop corrective action and prevention strategies
- Measure the financial and operational impact of prevention initiatives
- Lead transformation projects involving technology, analytics, automation, and workflow redesign
- Provide leadership to Managers, Team Leads, and clinical denial professionals, with a team size of minimum 50+
- Establish leadership development and succession-planning strategies
- Promote a culture of accountability, continuous improvement, and client service
- Ensure appropriate staffing models and organizational structures
- Oversee competency and training programs
- Ensure programs operate in accordance with regulatory requirements, payer policies, contractual obligations, and organizational standards
- Monitor emerging regulatory and reimbursement changes
- Identify operational and financial risks and develop mitigation strategies
Requirements:
- Bachelor’s degree in nursing, Healthcare Administration, Health Information Management, or related field
- Active RN license or applicable clinical credential
- 7+ years of healthcare experience, with substantial experience in clinical denials, CDI, RCM, utilization management, appeals, or reimbursement
- 3+ years of progressive leadership/management experience
- Demonstrated experience managing large-scale programs, multiple teams, or complex client engagements
- Strong understanding of inpatient DRG, medical necessity, level of care, clinical validation, coding, reimbursement, and payer policies
- Demonstrated financial and analytical acumen
- Excellent executive communication, presentation, negotiation, and stakeholder-management skills
- Preferred: CDAS or equivalent denial management credential
- Preferred: CCDS/CDIP or equivalent CDI certification
- Preferred: Master’s degree such as MHA, MBA, MSN, or related discipline
- Preferred: Experience with enterprise RCM transformation
- Preferred: Experience with Epic, payer portals, denial analytics, and business intelligence platforms
- Preferred: Experience managing multi-hospital or multi-client programs
- Preferred: Experience with automation, AI, analytics, or technology-enabled denial management
Benefits:
- Competitive salary
- Opportunity to shape the HR function of a rapidly growing BPO
- Work closely with a team of industry leaders who have successfully scaled BPOs in the past
- Career growth and development opportunities
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