Revenue Cycle Lead

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

📋 Description

• Act as the main internal authority on Athena claim edit rules, hold queues, and workflow configurations in relation to our non-FFS billing model.

• Collaborate closely with Athena's professional services/support team to establish and maintain tailored rules that suppress inappropriate low-dollar (“penny claim”) edits, and avoid unnecessary recalculations of allowable amounts or co-insurance on contracts where the full billed amount is recognized as the contracted rate.

• Convert payer contract specifications (including rate structures, encounter-reporting requirements, and invoicing agreements) into accurate system configurations.

• Sustain an up-to-date documentation repository of all custom rules, workarounds, and configuration decisions made within Athena, detailing their rationale and payer applicability.

• Ensure that claims are delivered to payers as intended and resolve discrepancies between submitted, accepted, and paid or invoiced amounts.

• Identify and resolve inappropriate Athena holds; differentiate between legitimate data/coding issues and false positives caused by FFS-oriented logic.

• Monitor and address partial payments, especially when Athena's allowable-amount logic contradicts contracted full-payment terms.

• Supervise the distinct plan-invoicing process for encounter/penny-claim arrangements, ensuring that invoices align with submitted encounters.

• Develop and uphold regular reports that cover: claim submission status, current holds and aging, partial payment/underpayment tracking, and payer-specific exception trends.

• Guide and evaluate the work of the Billing & Claims Analyst in generating and managing these reports.

• Conduct a structured 90-day evaluation of Athena's compatibility with our billing model and provide a clear recommendation: either continue to mitigate within Athena or explore transitioning to a different platform.

⛳️ Requirements

• Over 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 arrangements.

• Practical experience in configuring Athena (or a similar EMR/RCM platform), including collaboration with vendor support/professional services teams on custom edit rules and workflow modifications.

• Proficiency in reading and interpreting payer contract language, translating contractual terms into system requirements.

• Strong analytical and reporting capabilities; adept at creating reconciliation reports and effectively communicating findings to finance leadership.

• Proven ability to collaborate across functions with finance, operations, and external vendor teams, consistently advocating when a vendor's default assumptions do not align with the business model.

🏝️ Benefits

• Competitive salary and benefits package.

• Opportunities for professional development and ongoing education.

• A supportive and collaborative workplace environment.