Revenue Cycle & Claims Operations Lead

Emploi pas sur LinkedIn

🔥 il y a 11 heures

🐊 Florida – Distant

🐊 Florida – Remote

💵 $115 000 - $150 000 / an

⏰ Temps Plein

🟠 Senior

⚙️ Opérations

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Porter

Site WebLinkedInTous les Emplois

51 - 200 employés

🏥 Santé

⚕️ Assurance santé

🤖 Intelligence artificielle

💰 €5 400 000 Venture Round en 2023-01

Healthcare • Healthcare Insurance • Artificial Intelligence

Porter est une entreprise de coordination et de gestion des soins de santé qui exploite la puissance de l'intelligence artificielle pour connecter divers aspects de la prestation de soins de santé. Leurs services se concentrent sur la coordination des soins pour les payeurs, les particuliers, les familles et les prestataires à risque, en assurant une navigation fluide à travers le système de soins de santé et en améliorant la qualité des soins grâce à des évaluations à domicile et des interventions personnalisées. L'approche innovante de Porter traite des mesures de qualité, des ajustements de risque et de la fermeture des lacunes dans les soins, en particulier pour les membres de Medicare Advantage, Medicaid et ACA commercial. Ils mettent l'accent sur la réduction des réadmissions et sur l'amélioration de la qualité des soins grâce à leur portail de santé complet et à leurs guides de soins dédiés, qui apportent un soutien depuis la planification jusqu'à l'obtention de l'équipement médical et des services nécessaires.

Description

• Own the end-to-end assessment and mitigation of the mismatch between Porter’s payer-contracted billing model and Athena’s fee-for-service-oriented logic • Serve as the primary internal owner of Athena claim edit rules, hold queues, and workflow configuration • Partner with Athena professional services/support to build and maintain custom edit and workflow rules • Translate payer contract terms into system configuration and document custom rules, workarounds, and decisions • Ensure claims reach payers as intended and reconcile submitted, accepted, paid, and invoiced amounts • Identify and clear inappropriate Athena holds and resolve partial payments or underpayments • Oversee plan invoicing for encounter/penny-claim arrangements and reconcile invoices against submitted encounters • Design and maintain reports on claim status, holds and aging, underpayments, and payer-specific exceptions • Direct and review the Billing & Claims Analyst’s reporting work • Analyze recurring patterns and drive systemic fixes • Lead a structured 90-day assessment of Athena and recommend continued mitigation or migration to another platform • If migration is recommended, lead requirements gathering and RFP scoping for a replacement EMR/RCM system • Proactively recommend process, payer, system, and staffing changes

🎯 Exigences

• 5+ years of revenue cycle management or claims operations experience in healthcare • Direct hands-on experience with value-based care, risk adjustment, HEDIS/quality gap closure, delegated services, or other non-fee-for-service payer arrangements • Practical experience configuring Athena or a comparable EMR/RCM platform • Experience working with vendor support/professional services teams on custom edit rules and workflow changes • Ability to interpret payer contract language and translate contractual terms into system requirements • Strong analytical and reporting skills, including reconciliation report development • Ability to communicate findings to finance leadership • Demonstrated ability to work cross-functionally with finance, operations, and external vendor teams • Preferred: experience evaluating or migrating between EMR/RCM platforms • Preferred: familiarity with encounter data reporting standards and delegated/capitated payer relationships • Preferred: CRCR certification or equivalent • Preferred: experience managing or mentoring junior billing/claims staff

🏖️ Avantages

• Competitive wage and benefits package • Opportunities for professional growth and continuing education • A supportive, collaborative work environment