Revenue Cycle & Claims Operations Lead

ABOUT THE ROLE

Our organization operates in a payer-contracted services model — including delegated services, in-home assessments, HEDIS gap closure, and risk adjustment visits — rather than traditional fee-for-service care. Our billing patterns vary by payer and may include “penny claims” for encounter reporting paired with separate plan invoicing, or full-cost claims billed at the full contracted (allowable) rate.

Our EMR/RCM platform, Athena, is built around traditional fee-for-service economics: maximizing collections, flagging low-dollar claims as errors, and defaulting to standard allowable-amount and co-insurance logic. This creates a persistent structural mismatch with our billing model.

We are hiring a Revenue Cycle & Claims Operations Lead to own this problem end-to-end: to understand our payer contracts and billing models deeply, to configure and manage Athena as effectively as the platform allows, to build the reporting infrastructure needed to see what's actually happening to our claims, and to make a clear, well-supported recommendation on whether our long-term path is continued mitigation within Athena or migration to a different platform.

KEY RESPONSIBILITIES

• 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.

Claims Operations & Oversight

• 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.

Reporting & Analysis

• 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.
• Surface patterns (e.g., a hold type recurring across many claims for one payer) and use them to drive systemic fixes rather than one-off corrections.

Strategic Recommendations

• Lead a structured 90-day assessment of Athena's fit for our billing model (see companion scoping document) and deliver a clear recommendation: continue to mitigate within Athena, or scope a transition to an alternative platform.
• If migration is recommended, lead requirements-gathering and RFP scoping for a replacement EMR/RCM system suited to delegated/value-based billing models.
• Proactively bring forward recommendations — process changes, payer conversations, system configuration, or staffing — rather than waiting to be asked.

REQUIRED QUALIFICATIONS

• 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.

PREFERRED QUALIFICATIONS

• Prior experience evaluating or migrating between EMR/RCM platforms.
• Familiarity with encounter data reporting standards and delegated/capitated payer relationships.
• Certification such as CRCR (Certified Revenue Cycle Representative) or equivalent.
• Experience managing or mentoring junior billing/claims staff.