Revenue Cycle Manager

Department: Revenue Cycle

Reports To: Directors of Community Health & Operations

Classification: Exempt

Work Arrangement: Remote – California Based

Schedule: Monday – Friday | 8:30 AM – 5:00 PM

About Pacific Health Group

Pacific Health Group (PHG) is committed to improving health outcomes by addressing the medical, behavioral, and social needs of the communities we serve. Through programs such as Enhanced Care Management (ECM), Community Supports (CS), Community Health Worker (CHW) services, Behavioral Health, and other community-based healthcare programs, PHG works collaboratively with health plans, providers, community organizations, and other partners to support whole-person care.

Our work is grounded in accountability, collaboration, innovation, integrity, and a commitment to improving access to high-quality services for vulnerable and underserved populations.

Position Summary

The Revenue Cycle Manager is responsible for the leadership, oversight, performance, and continuous improvement of Pacific Health Group's Revenue Cycle operations.

This position oversees the full revenue cycle, including billing, coding, claims submission, payment posting, accounts receivable, collections, denials, appeals, payer reconciliation, reimbursement analysis, and revenue reporting.

The Revenue Cycle Manager ensures services are appropriately supported by documentation, claims and encounters are submitted accurately and timely, outstanding revenue is actively managed, reimbursement discrepancies are identified and resolved, and Revenue Cycle activities comply with payer, contractual, regulatory, and organizational requirements.

This position provides direct leadership and oversight to assigned Revenue Cycle staff and collaborates closely with the Directors of Community Health & Operations, Finance, Quality Assurance, Operations, program leadership, Information Technology, health plans, and other internal and external stakeholders.

The Revenue Cycle Manager is expected to operate with a high degree of independence, accountability, urgency, and ownership. This individual must proactively identify risks, establish measurable performance expectations, develop solutions, implement corrective actions, and drive issues through resolution without requiring repeated leadership intervention.

Essential Duties and Responsibilities

Revenue Cycle Management & Operational Oversight

• Lead the day-to-day operations and overall performance of Pacific Health Group's Revenue Cycle function.
• Oversee billing, coding, claims submission, payment posting, accounts receivable, collections, denials, appeals, and reimbursement activities.
• Establish and maintain effective workflows, internal controls, performance standards, and accountability measures.
• Ensure claims and encounters are submitted accurately and within applicable payer and timely-filing requirements.
• Monitor outstanding, rejected, denied, unpaid, and underpaid claims through resolution.
• Identify revenue leakage, reimbursement delays, and operational barriers affecting revenue.
• Proactively develop and implement corrective action plans when Revenue Cycle performance falls below expectations.
• Ensure Revenue Cycle issues are actively managed through resolution rather than remaining outstanding without documented action.
• Promptly escalate significant financial, compliance, payer, or operational concerns to the Directors of Community Health & Operations.

Billing, Coding & Documentation Integrity

• Ensure accurate billing and coding in accordance with applicable ICD-10, CPT, HCPCS, modifiers, payer requirements, contractual requirements, and organizational standards.
• Ensure billed services are supported by appropriate and complete documentation.
• Identify documentation deficiencies that may prevent billing, delay reimbursement, cause denials, or create compliance concerns.
• Partner with Quality Assurance, Operations, and program leadership to address recurring documentation and billing deficiencies.
• Monitor unbilled claims and encounters and ensure identified issues are resolved timely.
• Maintain current knowledge of payer billing requirements and communicate changes that may affect PHG operations.
• Develop preventive processes to reduce documentation-related denials and reimbursement delays.

Accounts Receivable & Collections

• Maintain direct oversight of accounts receivable and collection activities.
• Review A/R aging and outstanding balances by payer, program, aging category, and reimbursement status.
• Establish priorities and follow-up expectations for outstanding receivables.
• Monitor aged accounts receivable, including balances exceeding 90 and 120 days.
• Ensure timely and documented follow-up on unpaid and underpaid claims.
• Identify and recover reimbursement that may otherwise be lost due to underpayments, missed billing, denials, or untimely follow-up.
• Monitor adjustments, refunds, credit balances, and write-offs to ensure accuracy and appropriate authorization.
• Establish strategies to reduce aged receivables and improve cash flow.

Denials, Rejections & Appeals Management

• Oversee the denial and rejection management process from initial identification through final resolution.
• Monitor and analyze denial trends by payer, program, denial reason, service type, and other relevant categories.
• Conduct root-cause analysis of recurring denials and implement corrective action plans.
• Ensure corrected claims and appeals are submitted within required deadlines.
• Monitor denial overturn rates and revenue recovered through appeals.
• Collaborate with internal departments to address operational, authorization, eligibility, or documentation issues contributing to denials.
• Implement preventive strategies to reduce avoidable denials and improve clean claim and first-pass acceptance rates.

Payer & Health Plan Management

• Serve as a primary Revenue Cycle contact for health plans, insurance companies, and other payers regarding billing and reimbursement matters.
• Reconcile claims and encounters against accepted, rejected, denied, paid, and outstanding claims.
• Compare expected reimbursement against payments received and identify discrepancies.
• Review remittance information and payer documentation for accuracy.
• Identify and pursue underpayments, missing payments, incorrect payments, and other reimbursement discrepancies.
• Validate reimbursement against applicable payer contracts, fee schedules, and payment methodologies.
• Escalate systemic payer concerns and work with health plans through resolution.
• Track outstanding payer issues and maintain clear documentation of follow-up activities and outcomes.
• Support implementation of new payer contracts, amendments, fee schedules, billing requirements, and reimbursement methodologies.

Program & Cross-Departmental Collaboration

• Maintain working knowledge of billing, reimbursement, encounter, authorization, and documentation requirements applicable to PHG programs and contracted services.
• Support Revenue Cycle operations for Enhanced Care Management (ECM), Community Supports (CS), Community Health Worker (CHW), Behavioral Health, and other PHG programs as applicable.
• Partner with Operations and program leadership to ensure operational workflows support payer and reimbursement requirements.
• Partner with Quality Assurance to identify documentation and compliance issues affecting reimbursement.
• Collaborate with Finance regarding revenue reconciliation, payment activity, financial reporting, and internal controls.
• Partner with Information Technology to improve billing systems, EHR functionality, reporting, data integrity, integrations, and Revenue Cycle automation.
• Communicate recurring operational barriers, reimbursement trends, and payer concerns to the Directors of Community Health & Operations.
• Clearly identify departmental ownership when Revenue Cycle issues require action from another department and follow through until resolution.

Auditing, Compliance & Risk Management

• Conduct routine audits of billing, coding, claims, payment posting, collections, adjustments, and other Revenue Cycle activities.
• Ensure compliance with payer requirements, applicable state and federal healthcare billing regulations, contractual obligations, HIPAA, PHI requirements, and PHG policies.
• Maintain accurate and audit-ready Revenue Cycle documentation and records.
• Support payer, regulatory, external, and internal audits.
• Identify trends, root causes, and compliance concerns and implement corrective actions.
• Promptly escalate suspected improper billing, significant coding concerns, overpayments, or other material compliance risks.
• Ensure identified audit findings are assigned, corrected, tracked, and monitored for sustained compliance.

Reporting, Analytics & Performance

• Develop and maintain Revenue Cycle reports, dashboards, and performance analyses.
• Provide routine and structured Revenue Cycle performance updates to the Directors of Community Health & Operations.
• Ensure reports are accurate, actionable, timely, and provided proactively without requiring repeated requests from leadership.
• Monitor Revenue Cycle trends and identify areas requiring corrective action or leadership intervention.
• Support month-end revenue reconciliation and investigate significant differences between expected and actual reimbursement.
• Provide actionable recommendations to improve reimbursement, cash flow, operational efficiency, and financial performance.

Team Leadership & Performance Management

• Provide direct supervision, leadership, coaching, and support to assigned Revenue Cycle staff.
• Establish clear individual and departmental performance expectations.
• Conduct regular one-on-one meetings, team meetings, coaching sessions, and performance evaluations.
• Monitor staff productivity, quality, accuracy, timeliness, and achievement of assigned KPIs.
• Establish individual and departmental accountability for outstanding claims, denials, payer issues, and other Revenue Cycle responsibilities.
• Provide ongoing training regarding billing requirements, payer updates, workflows, compliance, and departmental procedures.
• Address performance deficiencies promptly and partner with Human Resources regarding corrective action or progressive discipline when appropriate.
• Evaluate departmental staffing, workloads, workflow distribution, and resource needs.
• Ensure appropriate coverage and operational continuity during employee absences.
• Foster a culture of accountability, collaboration, accuracy, professionalism, urgency, and continuous improvement.

Process Improvement & Standard Operating Procedures

• Develop, maintain, and enforce Revenue Cycle policies, procedures, workflows, and standard operating procedures.
• Maintain documented procedures for billing, claims, collections, denials, appeals, payment posting, adjustments, write-offs, reconciliations, and payer escalations.
• Continuously evaluate Revenue Cycle processes for accuracy, efficiency, compliance, and scalability.
• Identify opportunities to automate processes, reduce manual errors, and improve productivity.
• Lead initiatives designed to reduce denials, decrease aged receivables, minimize write-offs, improve reimbursement timelines, and strengthen cash flow.
• Ensure departmental procedures remain current as payer, regulatory, contractual, system, and organizational requirements change.
• Establish tracking mechanisms to ensure process improvements result in measurable and sustained performance improvement.

Key Performance Indicators (KPIs)

The Revenue Cycle Manager is responsible for monitoring, reporting, and improving Revenue Cycle performance. Key performance indicators may include:

• Days in Accounts Receivable.
• A/R aging.
• Percentage of A/R greater than 90 and 120 days.
• Clean claim rate.
• First-pass claim acceptance rate.
• Claim rejection rate.
• Denial rate.
• Denial overturn and recovery rate.
• Collection performance.
• Timely filing compliance.
• Unbilled claims and encounters.
• Underpayment identification and recovery.
• Write-offs and adjustments.
• Revenue leakage identification and recovery.
• Payer reimbursement trends.
• Payment posting and reconciliation accuracy.
• Timely resolution of payer discrepancies.
• Staff productivity, quality, and accuracy.
• Timeliness and accuracy of Revenue Cycle reporting.
• Audit readiness and compliance performance.

Performance metrics and departmental targets may be modified based on organizational, contractual, payer, and operational requirements.

Leadership & Accountability Expectations

The Revenue Cycle Manager is expected to operate as the accountable leader for the Revenue Cycle function and demonstrate consistent ownership of departmental outcomes.

This includes:

• Independently identifying problems within the scope of Revenue Cycle responsibility.
• Developing and implementing appropriate solutions.
• Following identified issues through final resolution.
• Maintaining visibility into departmental performance and outstanding risks.
• Providing leadership with timely and accurate information.
• Proactively communicating barriers rather than waiting for leadership to identify them.
• Holding Revenue Cycle team members accountable for assigned responsibilities and performance expectations.
• Maintaining organized tracking systems for open issues, payer escalations, denials, receivables, and corrective actions.
• Demonstrating measurable and sustained improvement in Revenue Cycle performance.

Significant financial, compliance, operational, or payer-related risks must be promptly escalated to the Directors of Community Health & Operations.

Work Environment

• Remote, California-based position.
• Full-time schedule, Monday through Friday, 8:30 AM–5:00 PM, with flexibility based on organizational needs.
• Occasional in-person attendance may be required for meetings, trainings, departmental activities, or organizational events.
• Fast-paced and highly accountable environment requiring strong organization, analytical thinking, problem-solving, independent judgment, and proactive communication.
• Must maintain confidentiality and appropriately safeguard financial information, member information, payer information, and protected health information.
• Must work collaboratively across departments while maintaining clear accountability for Revenue Cycle responsibilities.

Performance Expectations

The Revenue Cycle Manager is expected to demonstrate measurable and sustained improvement in Revenue Cycle performance, including billing accuracy and timeliness, collection performance, accounts receivable, denial prevention and resolution, reimbursement recovery, reporting accuracy, payer issue resolution, staff performance, and compliance.

The Revenue Cycle Manager is expected to independently identify problems within their scope of responsibility, develop appropriate solutions, implement corrective actions, and follow matters through resolution.

Performance concerns, recurring operational barriers, payer issues, and significant financial or compliance risks must be communicated proactively and promptly to the Directors of Community Health & Operations.

Requirements

Minimum Qualifications

• Minimum of five (5) years of experience leading healthcare revenue cycle operations across billing, denials, and accounts receivable.
• Experience supporting CalAIM Enhanced Care Management (ECM), Community Supports, Community Health Worker programs, Behavioral Health, or similar community-based healthcare services.
• Experience managing multiple payer relationships and reimbursement methodologies.
• Strong working knowledge of ICD-10, CPT, HCPCS, payer rules, and claims adjudication.
• Knowledge of healthcare billing compliance requirements, HIPAA, and protection of PHI.
• Proficiency with healthcare billing platforms, EHR systems, reporting tools, and advanced Excel analysis.
• Strong analytical skills with demonstrated ability to identify trends, conduct root-cause analysis, and implement corrective actions to improve denial rates, cash flow, and revenue integrity.
• Based in California.

Preferred Qualifications

• Bachelor's degree in Healthcare Administration, Finance, Accounting, Business Administration, or a related field; equivalent relevant experience may be considered.
• Holds a Certified Professional Coder (CPC), Certified Revenue Cycle Representative (CRCR), Certified Revenue Cycle Professional (CRCP), or related revenue cycle credential.
• Experience managing Medi-Cal or California managed care reimbursement processes.
• Experience working within a rapidly growing healthcare organization.