Revenue Cycle Lead

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🔥 3 minutes ago

🐊 Florida – Remote

🐊 Florida – Remote

💵 $115k - $150k / year

⏰ Full Time

🟠 Senior

💹 Revenue Operations

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Porter

WebsiteLinkedInAll Job Openings

51 - 200 employees

⚕️ Healthcare Insurance

🤖 Artificial Intelligence

☁️ SaaS

💰 $5.4M Venture Round on 2023-01

Healthcare Insurance • Artificial Intelligence • SaaS

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

• Serve as the primary internal owner of Athena claim edit rules, hold queues, and workflow configuration as they relate to our non-FFS billing model. • Partner directly with Athena's professional services/support team to build and maintain custom rules that suppress inappropriate low-dollar (“penny claim”) edits and prevent unwanted allowable-amount or co-insurance recalculation on contracts where the full billed amount is the contracted rate. • Translate payer contract terms (rate structures, encounter-reporting requirements, invoicing arrangements) into correct system configuration. • Maintain a living documentation set of every custom rule, workaround, and configuration decision made in Athena, including rationale and payer applicability. • Ensure claims are reaching payers as intended and reconcile discrepancies between what was submitted, what was accepted, and what was paid or invoiced. • Identify and clear inappropriate Athena holds; distinguish true data/coding issues from false positives generated by FFS-oriented logic. • Track and resolve partial payments, particularly where Athena's allowable-amount logic conflicts with contracted full-payment terms. • Oversee the separate plan-invoicing process for encounter/penny-claim arrangements, ensuring invoices reconcile against submitted encounters. • Design and maintain recurring reports covering: claim submission status, current holds and aging, partial payment/underpayment tracking, and payer-specific exception trends. • Direct and review the work of the Billing & Claims Analyst in building and running these reports. • Lead a structured 90-day assessment of Athena's fit for our billing model and deliver a clear recommendation: continue to mitigate within Athena or scope a transition to an alternative platform.

🎯 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), including working with vendor support/professional services teams on custom edit rules and workflow changes. • Ability to read and interpret payer contract language and translate contractual terms into system requirements. • Strong analytical and reporting skills; comfortable building reconciliation reports and communicating findings to finance leadership. • Demonstrated ability to work cross-functionally with finance, operations, and external vendor teams, and to advocate persistently when a vendor's default assumptions don't fit the business model.

🏖️ Benefits

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