Cartwheel

Operations

• Conduct structured analysis of denial and rejection data to identify root causes, payer patterns, and filing limit exposure
• Move beyond rework — trace denial and rejection spikes to upstream workflow, documentation, or submission failures and drive fixes at the source
• Build and maintain AR aging trend tracking and recoverable revenue opportunity analysis
• Execute claim corrections, resubmissions, and payer follow-up as a hands-on operational contributor
• Build and maintain operational dashboards (Looker preferred) that give RCM leadership real-time visibility into denial volume, payer performance, and AR trends
• Produce clear, prioritized findings from claim-level data using pivot tables, formulas, and BI tooling
• Design reporting outputs so findings are actionable and accessible to non-billing stakeholders — not just data-literate audiences
• Translate billing logic, payer-specific rules, and denial patterns into written, maintainable SOPs
• Build operational workflow guides prioritized by highest-volume and highest-denial-rate categories first
• Ensure documentation is usable by team members without direct guidance, so operational knowledge scales beyond any one person
• Partner with clinical teams to identify upstream documentation or workflow gaps contributing to denials and rejections
• Validate billing logic and payer requirements in collaboration with RCM leadership
• Communicate findings and recommendations in plain language to non-billing stakeholders including clinical and operations partners
• Support training and internal knowledge base development as the operational RCM subject matter resource

RCM Operations Analyst

Director

• Own clinical quality strategy for a rapidly scaling network spanning 20+ states, 400+ clinicians, and multiple care models.
• Design and operationalize frameworks for performance monitoring, documentation standards, and audit readiness that are built to scale — not patched as the organization grows.
• Translate regulatory requirements into practical workflows.
• Present quality trends, risk signals, and improvement recommendations to the extended leadership team alongside peers in Clinical, Operations, and Product.
• Inform board-level reporting on clinical risk and compliance posture.
• Define what effective, evidenced based clinical supervision looks like at Cartwheel and build the systems to measure and develop it.
• Own HIPAA compliance, incident management, complaint and grievance workflows, and payer audit readiness across all operating jurisdictions.
• Build clinical compliance policy infrastructure that anticipates growth rather than reacts to it.
• Set the performance standard for Cartwheel's clinician network — not just identify when it's missed.
• Lead and develop a team that grows with the organization.

Director of Clinical Quality

Controller

• Own core processes including month-end close, reconciliations, controls, and reporting.
• Design scalable accounting policies and workflows.
• Lead the transition from outsourced accounting function to fully in-house
• Evaluate and select a modern ERP (NetSuite, Intacct, Rillit, etc.) with cross-functional partners.
• Own configuration, chart of accounts design, integrations, and process buildout.
• Establish a strong, audit-ready financial infrastructure from day one.
• Lead GAAP-compliant reporting and technical accounting decision-making.
• Prepare Cartwheel for its first (or subsequent) external audit.
• Manage documentation, controls, and alignment with auditors and internal teams
• Hire a Staff Accountant shortly after onboarding.
• Provide mentorship, clarity, and development as the team grows.
• Work with BizOps and Data to connect financial reporting to operational metrics (RCM, state P&L, revenue quality).
• Collaborate with RCM and Health Plan Ops on payer dynamics, collections, and revenue integrity.
• Support leadership with budgeting, forecasting, and board reporting.

Medical Billing and Coding

• Perform complex coding for CPT, HCPCS, and ICD-10 with a focus on high-impact, payer-sensitive services
• Lead expansion and validation of new and underutilized codes (e.g., 90785, T1016, G-codes, state-specific Medicaid codes)
• Apply and validate advanced modifier usage, including Medicaid and MCO-specific requirements, to ensure accurate reimbursement
• Conduct deep-dive research on payer policies, fee schedules, and billing requirements across Medicaid, MCOs, and commercial plans
• Establish coding standards and best practices across the organization
• Serve as the subject matter expert (SME) for coding logic in automation and AI initiatives
• Translate complex coding rules into scalable system logic for upstream claim automation
• Perform manual chart reviews using Medical Decision Making (MDM) guidelines
• Validate appropriate E/M level selection
• Identify opportunities for appropriate upcoding where documentation supports higher acuity
• Establish a 'gold standard' baseline for CPT coding accuracy
• Lead analysis of coding-related denials and rejections, including diagnosis and modifier-related issues
• Identify root causes and drive upstream fixes to prevent recurrence
• Provide expert guidance on complex denial scenarios and appeals strategy, particularly for Medicaid and MCO plans
• Support review of payment discrepancies (paid vs. expected based on fee schedules)
• Provide coding insight into payer behavior and reimbursement variances across Medicaid and MCOs
• Work closely with Clinical teams to ensure documentation supports coding accuracy
• Partner with RCM leadership on billing strategy and optimization initiatives
• Support training and documentation (e.g., SOPs, internal knowledge base content)

RCM Operations Analyst

Director of Clinical Quality

Controller

Medical Coder – Medicaid, Behavioral Health