Process Analyst/SME (US Healthcare RCM)

Product Development Position Overview

We are seeking a Process Analyst / Subject Matter Expert (SME) to provide deep domain expertise in the full US Healthcare Revenue Cycle Management (RCM) lifecycle, driving process optimization, AI/ML adoption, automation, and operational excellence.

The role spans the entire RCM cycle: Patient Registration Eligibility Perks Prior Authorization Coding Documentation Charge Capture Claims Submission Payment Posting Denial Management Collections Reporting .

The SME will focus on full RCM workflows, payer systems, EHR/EMR/PMS integrations, EDI transactions, coding standards, payer portals, and payer databases (e.g., NCCi, AAPC, AHIMA, AMA), ensuring compliant, scalable, and data-driven RCM operations and supporting analytics, AI/automation, and dashboard/reporting initiatives for US healthcare operations.

The role collaborates with business analysts, data scientists, RPA engineers, AI/ML teams, system/application analysts developers, and clients to implement AI-driven process improvements.

Job Roles Responsibilities

End-to-End RCM Process Expertise :

- Analyze and optimize full RCM workflows, including Patient Registration, Eligibility Verification, Prior Authorization, Coding, Charge Capture, Claims Submission, Payment Posting, Denial Management, Collections, and Reporting.
- Map detailed process flows, exceptions, and system interactions for RCM operations.
- Maintain best-practice SOPs aligned with compliance, AI/automation, and system integrations.
- Leverage knowledge of payer databases, payer websites, and industry standards (NCCi, AAPC, AHIMA, AMA) to validate claims and workflows.
- Serve as domain expert across the full RCM cycle:
- Patient Registration Scheduling

- Eligibility Benefits Verification

- Prior Authorization

- Medical Coding (ICD-10, CPT, HCPCS)

- Claims Submission Management

- Denials Management Collections

- Revenue Reconciliation Financial Reporting

- Identify process gaps, inefficiencies, and automation opportunities within RCM workflows.

EHR/EMR/PMS System Expertise :

- Work with EHR/EMR platforms, PMS systems, and integrated billing systems to align business processes with operational and AI workflows.




- Collaborate with System/Application Analysts to ensure workflows translate into functional requirements.
- Validate RPA, AI agents, and automation integrations within healthcare IT systems.

Payer Market Intelligence

- Maintain expertise on payer systems, portals, and clearinghouses:
- Commercial payers: UnitedHealthcare, Anthem, Aetna, Cigna, Humana, Blue Cross/Blue Shield

- Government payers: Medicare, Medicaid

- Clearinghouses: Availity, Change Healthcare, Optum, RelayHealth, Trizetto

- Conduct market research on payer rules, reimbursement policies, adjudication workflows, and claims lifecycle.
- Maintain knowledge of professional coding billing standards: AAPC, AHIMA, AMA CPT, ICD-10, HCPCS, NCCI edits.

AI/ML Automation Enablement :

- Identify opportunities for AI/ML, GenAI, LLM-based agents, and Agentic AI in RCM workflows.
- Partner with data scientists and RPA engineers to operationalize predictive models, agentic AI, and automated decision-making.
- Support multi-agent orchestration, workflow automation, and analytics-driven process improvements.

Training, Mentorship Knowledge Transfer :

- Serve as domain authority for cross-functional teams including AI, RPA, system analysts, and client stakeholders.
- Conduct training sessions, workshops, and knowledge transfer for RCM systems, AI workflows, and compliance processes.
- Develop process manuals, SOPs, and training materials integrating full RCM cycle knowledge with AI/automation best practices.

Technical Collaboration :

- Collaborate with Product, Engineering, Data, AI/ML, RPA, and DevOps teams to translate business and process requirements into technical solutions.
- Support design and validation of end-to-end RCM tools, including workflow automation, AI/GenAI models, and multi-agent orchestration.
- Work closely with data scientists, AI/ML engineers,



cloud architectures, RPA developers, and DevOps teams to ensure business requirements are translated into scalable, compliant solutions.
- Support LLM Ops, MLOps, and Agentic AI deployment by defining input/output requirements, monitoring KPIs, and validating results.
- Assist in integration of AI predictions and autonomous agent outputs into RCM and cloud workflows.

Analytics, Reporting Insights :

- Define KPIs, dashboards, and reporting frameworks for operational, financial, and compliance performance.
- Collaborate with data and analytics teams to ensure data accuracy, integrity, and actionable insights.
- Conduct deep analysis of RCM projects, identifying trends, bottlenecks, and revenue optimization opportunities.

Compliance Governance :

- Ensure adherence to HIPAA, SOC 2, GDPR, and internal healthcare compliance standards.
- Maintain audit-ready documentation for AI/ML models, RPA workflows, and process changes.
- Implement data governance and process validation frameworks for operational reliability.

Stakeholder Management :

- Serve as the liaison between technical teams, product owners, and business stakeholders.
- Facilitate workshops, requirement reviews, and solution validation sessions.

Candidate Requirements

- Bachelor s or Master s degree in Healthcare Administration, Health IT, Business Analysis, or related field.
- 7 12+ years in US Healthcare RCM, with hands-on experience across full-cycle processes.
- Strong knowledge of payer systems, EHR/EMR, PMS, clearinghouses, and EDI standards.
- Experience collaborating with technical teams to design automated, AI-enabled, and analytics-driven RCM workflows.
- Proven understanding of coding, billing, claims adjudication, and healthcare compliance.

Technical Expertise :

- EHR/EMR PMS: Epic, Cerner, Allscripts, Meditech, AthenaHealth, NextGen
- Payer Portals Clearinghouses: Availity, Change Healthcare, Optum, RelayHealth, Trizetto

Disclaimer : This job posting has been aggregated from external source. Role details, content, and availability are subject to change. Applicants are advised to confirm the latest information directly on the company website before applying.

📌 Process Analyst/SME (US Healthcare RCM) (Pune)
🏢 Credence Resource Management
📍 Pune