PFS Operations Director

Summary:

The role is a senior, hands-on operational leader who embeds with a large health system client to drive transformation across hospital and professional billing. The role is paired seat-for-seat with the client leader who owns hospital billing and denials today – two in the box, one roadmap, one number - and owns the area’s results end to end: denials, A/R, underpayments, timely filing, and the work queue and operating model that produce them.

This is an operator’s role, not an advisory one. The PFS Operations Lead works in the client’s Epic environment and inside its work queues to change performance: lowering denial rates and write-offs, reducing aged A/R and A/R days, recovering underpayments, and giving every account class a named owner and an aging standard. The role co-chairs the client’s Denial Prevention Committee and holds vendors and managed services partners to the same standards as internal teams, and reports results that reconcile to

the client’s own data and are validated by its Finance team.

The right candidate brings the pattern library of what top-quartile PFS performance looks like, the Epic Resolute depth to direct work queue and automation design, and the credibility to lead directors, managers, and payer-facing teams through change. This is a high-visibility seat on a compact, senior transformation team, with direct executive exposure at the client and a clear path into senior consulting and operations leadership at Healthrise.

Duties and Responsibilities

Hospital & Professional Billing Transformation Leadership

• Knows, understands, incorporates, and demonstrates the Healthrise Core Values in all interactions with team members, clients, and stakeholders.

• Serve as the Healthrise counterpart to the client’s hospital billing and denials leaders, co-owning a single integrated plan, one set of KPIs, and one financial target for PFS.

• Lead hospital (HB) and professional (PB) billing performance improvement against primary denial rate, insurance A/R over 90 days, A/R days, net collection ratio, write-off run rate, and cost to collect.

• Establish baselines, targets, and glidepaths, and convert them into baselined, sized, owner-assigned initiatives with quarterly gates.

• Work alongside client managers, supervisors, and frontline staff in daily operations and work queues to restore throughput and close gaps; lead through influence and the paired-leader model, with decisions resting with the client.

• Partner with the Transformation Program Lead and the other paired leads to sequence cross functional dependencies (for example, a front-end authorization fix that is also a denial fix).

Denial Prevention & Management

• Co-chair the client’s Denial Prevention Committee with the client’s denials owner: run the weekly working session, report monthly to the executive steering committee, and hold initiative owners accountable.

• Run the monthly root-cause cycle - randomized sampling of denied and written-off claims, final rootcause determination, candidate solutions drafted with affected department leaders - and track resulting impact in the benefits ledger.

• Build payer-specific playbooks and escalation paths for denial spikes and high-dollar categories (authorization, non-covered, medical necessity, coordination of benefits, timely filing), engaging payer relations and managed care contracting as needed.

• Lead timely filing elimination through workqueue routing, aging discipline, and claim status automation.

• Drive appeals strategy and denial-prediction capabilities, including denial appeal assistants, overturn rate improvement, and appeal recovery.

• Work with patient access, revenue integrity, and clinical leaders so denial root causes are eliminated upstream rather than reworked downstream.

A/R, Follow-Up & Underpayments

• Reduce aged A/R and A/R days through follow-up strategy, account prioritization, and productivity standards applied consistently across HB and PB.

• Lead underpayment programs from workflow through automation, including variance identification, payer platform integration, and coordination with managed care contracting.

• Drive adoption of claim status automation and follow-up automation, including claim status autofollow-up and AI-enabled follow-up agents.

• Oversee billing activity workflow optimization, adjustment and refund review work queues, claim attachments, payment posting automation, and bad-debt and early-out agency performance.

• Provide vendor performance oversight: hold managed services partners and agencies to the same redesigned work queues, productivity standards, SLAs, and reporting as internal teams, and bring scope, price, and exit recommendations to executive review.

Work Queue Optimization & Operating Model Design

• Conduct a full work queue census (ownership, criteria, aging, touch patterns) and redesign routing and ownership so every account class has a named owner and an aging SLA.

• Implement work queue prioritization and Epic work queue automation, including simple criteria, auto retest, and auto-indexed correspondence, to reduce touches per claim.

• Define productivity and quality standards applied identically across internal, vendor, and Healthrise delivered capacity, along with spans of control, role design, and workforce transition plans aligned to attrition and automation timing.

• Establish quality controls, including stratified audit, first-pass accuracy standards, and error-pattern re-education.

Epic Optimization & Automation Adoption

• Direct Epic design, prioritization, and validation for HB and PB workflows, including Resolute work queues, claim edits, denial and follow-up tools, payment posting, and payer platform integration, in partnership with the paired Epic lead and Epic technical analysts.

• Translate operational requirements into build specifications, test scripts, training curricula, tip sheets, and at-the-elbow support; lead hypercare through stabilization against defined exit criteria.

• Activate Epic-native denial and follow-up AI and automation capabilities as they are released, with a baseline, hours-and-dollars target, and monthly adoption scorecard for each.

Value Realization, Governance & Knowledge Transfer

• Develop initiative charters and business cases with baseline, target, ramp, and validation method; post benefits to a single validated ledger with client Finance and avoid double-counting across initiatives.

• Present progress, risks, and decisions at weekly pair reviews, weekly operational calibration, monthly executive performance reviews, and quarterly business reviews.

• Lead change management embedded in every initiative: sponsor cascades, super-user networks, communication plans, and adoption measurement.

• Mentor and coach client directors, managers, and supervisors, and leave behind documented workflows, work queue configuration, SOPs, dashboards, and performance history so the client can sustain results independently.

• Ensure all work complies with federal and state billing regulations, HIPAA, CMS and payer policies, and client standards.

• Performs other duties as assigned.

Required

• Bachelor’s degree in Healthcare Administration, Business, Finance, or a related field; or equivalent combination of education and progressive experience.

• Minimum 10 years of progressive hospital and professional billing experience, including at least 5 years in a senior operational leadership role (director level or above) within a large health system or academic medical center.

• Demonstrated record of directly leading operational transformation and owning measurable outcomes (for example, reduced denial rates and write-offs, lower aged A/R, improved net collection ratio) – not solely advising or recommending.

• Deep expertise in denials management (prevention, root-cause analysis, appeals), A/R follow-up, underpayment recovery, and timely filing across HB and PB.

• Hands-on Epic expertise in HB and PB billing, including Resolute work queues, claim edits, and followup and denial tools, with the ability to direct design, build prioritization, testing, and activation.

• Proven experience designing and optimizing work queues, productivity and quality standards, and staffing and role models in a large, multi-site operation.

• Experience overseeing vendors or managed services partners, including performance management, SLAs, and scope or price decisions.

• Working knowledge of payer relations and escalation, including government and Medicaid payers, and of CMS and payer billing rules.

• Strong analytical skills: ability to interpret denial, A/R, and write-off data, benchmark against HFMA MAP Keys-aligned standards, and translate findings into prioritized action plans.

• Exceptional written and verbal communication skills; comfortable presenting to executive leadership, clinical leaders, and frontline staff, and influencing across organizations.

• Proficiency in Microsoft Office (Outlook, Word, PowerPoint, Excel).

• Completion of regulatory/mandatory certifications as required.

• Willingness and ability to travel to client or organizational sites as needed.

Preferred

• Master’s degree (MHA, MBA, or equivalent).

• Epic certification(s) in relevant billing modules (for example, Resolute Hospital Billing, Resolute Professional Billing, or Claims and Remittance).

• Certified Revenue Cycle Professional (CRCP), Certified Revenue Cycle Representative (CRCR), HFMA Fellow (FHFMA), Certified Professional Coder (CPC), or equivalent industry certification.

• Lean Six Sigma Green Belt or Black Belt; experience facilitating rapid improvement events and root cause workshops.

• Experience with AI and automation applied to denials, claim status, follow-up, or underpayments (RPA, intelligent denial routing, AI-assisted appeals).

• Experience in a safety-net, academic, or Medicaid-heavy health system environment.

• Experience leading vendor consolidation or managed services transitions, including workforce transition planning with HR.

• Prior consulting, managed services, or embedded-leadership experience supporting multiple client organizations.

• Experience building initiative business cases validated by Finance, including benefits ledgers and glidepath tracking.

• Familiarity with the No Surprises Act, price transparency requirements, and other regulatory developments affecting hospital and physician billing.