Revenue Cycle & Claims Operations Lead

This is a fully remote position, open to applicants in Florida.

📋 Description

• Take ownership of the comprehensive evaluation and resolution of discrepancies between Porter’s payer-contracted billing framework and Athena’s fee-for-service logic.

• Act as the primary internal authority on Athena claim edit rules, hold queues, and workflow configurations.

• Collaborate with Athena professional services and support teams to develop and sustain customized edit and workflow rules.

• Convert payer contract terms into system configurations and document tailored rules, workarounds, and decisions.

• Ensure claims are directed to payers as planned and reconcile amounts that are submitted, accepted, paid, and invoiced.

• Identify and resolve inappropriate Athena holds and address partial payments or underpayments.

• Supervise plan invoicing for encounter/penny-claim arrangements and reconcile invoices with submitted encounters.

• Create and maintain reports on claim statuses, holds and aging, underpayments, and payer-specific exceptions.

• Guide and review the reporting work of the Billing & Claims Analyst.

• Analyze recurring trends and implement systemic solutions.

• Conduct a structured 90-day assessment of Athena and propose continued mitigation strategies or migration to an alternative platform.

• If migration is advised, lead the requirements gathering and RFP scoping for a replacement EMR/RCM system.

• Proactively suggest changes in processes, payers, systems, and staffing.

⛳️ Requirements

• Minimum of 5 years of experience in revenue cycle management or claims operations within the healthcare sector.

• Direct, hands-on experience with value-based care, risk adjustment, HEDIS/quality gap closure, delegated services, or other non-fee-for-service payer models.

• Practical experience in configuring Athena or a similar EMR/RCM platform.

• Experience collaborating with vendor support and professional services teams on custom edit rules and workflow modifications.

• Capability to interpret payer contract language and convert contractual terms into system requirements.

• Strong analytical and reporting capabilities, including the development of reconciliation reports.

• Proficient in communicating findings to finance leadership.

• Proven ability to work collaboratively across functions with finance, operations, and external vendor teams.

• Preferred: experience in evaluating or migrating between EMR/RCM platforms.

• Preferred: knowledge of encounter data reporting standards and delegated/capitated payer relationships.

• Preferred: CRCR certification or equivalent.

• Preferred: experience in managing or mentoring junior billing/claims staff.

🏝️ Benefits

• Competitive salary and benefits package.

• Opportunities for professional development and continuing education.

• A supportive and collaborative work environment.