RCM Onboarding
A clear path from access and SOP capture to QA calibration, coverage, dashboards, and change control — with a week-by-week plan and RACI so everyone knows what to do.
Week-by-Week
Phase
Week 0 (Prep)
- Kickoff: confirm RCM lanes (eligibility, charge entry, claims, rejections, AR/denials, auths, coding QA) and success metrics
- BAA/DPA as needed; security & privacy review; sub-processor add (if applicable)
- Access checklist: EMR/PM, clearinghouse, payer portals, IVR, SSO/VDI/RBAC, IP allowlists
- Artifacts request: SOPs, payer policy links, edit rules, example claims/evidence, denial letter samples
Phase
Week 1
- Least-privilege access provisioned; JML owners named on both sides
- Shadow & SOP walkthroughs; draft defect taxonomy by lane (LCD/NCD, NCCI, modifiers, medical necessity)
- Coverage grid draft (shifts, surge buffers) with interval math sized to arrival patterns
- Dashboard definitions draft: clean-claim %, FPY, auth TAT, AR aging buckets, win-rate
Phase
Week 2
- Calibration v1: sample reviews with AQL targets and exemplars (by specialty/payer)
- Pod setup & cross-training matrix; coaching notes workflow in the EMR/PM context
- Ticketing flows for change control, incidents, and exceptions
- Pilot success gates finalized (e.g., FPY p50/p90, rejection TAT, AR burn-down)
Phase
Week 3
- Pilot start: daily huddles & scorecards; definitions embedded next to worklists
- Dashboards wired (read-only queries/exports) with drill-to-evidence tiles
- Incident Response alignment (severities, notify windows, PHI handling)
Phase
Week 4+
- Pilot checkpoint & go/no-go against gates
- Scale plan or migration to Managed Outcomes (SLAs/credits) if selected
- PIR cadence; continuous improvement backlog & owners
Access & Security
- SSO (preferred) or least-privilege user accounts for EMR/PM, clearinghouse, payer portals
- Network control: IP allowlists or VPN/VDI; device posture where required
- Join/Move/Leave (JML): named approvers and quarterly access reviews
- Secrets rotation cadence; shared vaults where applicable
QA & Calibration
- Defect taxonomy tied to payer policy/SOP version with concrete examples
- AQL sampling targets by lane/specialty; dual-review on high-risk classes
- Calibration cadence (weekly initially), FP/FN analysis and reviewer agreement
- Coaching notes linked to defects; recurrence watchlists and drift checks
Dashboards & Evidence
- Metric definitions cataloged next to each chart to prevent drift
- Clean-claim %, first-pass yield, rejection TAT, AR aging, denial win-rate
- SLA attainment (p50/p90), QA %, defect mix with drill-to-evidence
- Executive roll-up plus lane-level deep dives
Change Control
- Ticketed SOP/policy updates with effective dates and training attestations
- Versioned templates (macros, evidence, appeals) with named owners
- Release windows & rollback procedures for rules/edits
- Audit trail exports on request
RACI
| Role | Responsibilities |
|---|
| Client Sponsor | Approves scope, commercials, and success metrics |
| Client RCM Owner | SOPs/policies & access, reviews definitions/QA, resolves blockers |
| Carenox Delivery Lead | Owns timeline, pods, QA, and dashboards; weekly notes/QBRs |
| Carenox QA Lead | Taxonomy, AQL plan, calibration & coaching; drift prevention |
| Carenox Security/Trust | Access, BAA/DPA, sub-processors, IR mapping |
| Joint WFM/Analyst | Coverage math, surge buffers, and metrics wiring |
Ready to onboard?
We’ll map access, finalize QA & coverage, and start a pilot with clear success gates.
