Revenue Cycle & Claims Operations Lead

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🔥 0 minutes ago

🐊 Florida – Remote

🐊 Florida – Remote

💵 $115k - $150k / year

⏰ Full Time

🟠 Senior

⚙️ Operations

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Porter

WebsiteLinkedInAll Job Openings

51 - 200 employees

🏥 Healthcare

⚕️ Healthcare Insurance

🤖 Artificial Intelligence

💰 $5.4M Venture Round on 2023-01

Healthcare • Healthcare Insurance • Artificial Intelligence

Porter is a healthcare coordination and management company that leverages the power of artificial intelligence to connect various aspects of healthcare delivery. Their services focus on coordinating care for payers, individuals, families, and at-risk providers, ensuring seamless navigation through the healthcare system and improving care quality through in-home assessments and personalized interventions. Porter's innovative approach addresses quality measures, risk adjustments, and gap closures in care, particularly for Medicare Advantage, Medicaid, and ACA commercial members. They emphasize reducing readmissions and enhancing care quality through their comprehensive health portal and dedicated care guides, who provide support from scheduling to securing necessary medical equipment and services.

📋 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

🎯 Requirements

• 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

🏖️ Benefits

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