Revenue Integrity Specialist

Privia Health™ is a technology-driven, national physician enablement company that collaborates with medical groups, health plans, and health systems to optimize physician practices, improve patient experiences, and reward doctors for delivering high-value care in both in-person and virtual settings.

About the role

Under the direction of the Sr. Manager, Revenue Integrity and/or Sr. Manager, Revenue Optimization, the Revenue Integrity Specialist is responsible for complete, accurate, and timely processing of reimbursement/payment audits in compliance with Privia policies, payer contracts, and government fee schedules. This position also addresses requests for Care Center payment performance audits to assist in maximizing cash flow, as well as tracking and reporting the outcomes of both standard payer audits and requested Care Center audits. The role works collaboratively with operations consultants, RCM AR staff, and management.

Responsibilities

• Audit across all systems to ensure new provider and care center information is accurate.
• Ensure reimbursement by payer is accurate per payer contract agreements, government, and state rates by auditing payer-processed claims.
• Conduct Care Center audits following the audit policy based on the number of providers at 30/60/90/120 days post-implementation/go-live date.
• Assist the Sr. Manager, Revenue Integrity in leading initiatives that drive efficiency and partner internally and externally to deliver expected results (e.g., monthly market meetings with leadership, internal team meetings, and meetings with top commercial payers).
• Make independent decisions regarding audit results, communicate with appropriate teams (contract negotiators, senior leaders, market leaders, and/or directly with the payer) to ensure optimal revenue opportunity.
• Create, follow, and ensure adherence to approved escalation processes for timely issue resolution and completion of action plans.
• Identify, monitor, and manage denial management trends; work closely with Revenue Cycle Teams, payer representatives, and create one-pagers/reference tools on payer policies.
• Assist with Trizetto/Cognizant setup and fee schedule setup.
• Work and address Salesforce cases along with athenaOne tables.
• Perform other duties as assigned focused on key performance and department goals.

Requirements

• High School Graduate.
• 3+ years of experience in a medical billing office.
• Google Sheets/Microsoft Excel skills (e.g., pivot tables, VLOOKUP, sort/filtering, and formulas).
• 3+ years of experience with payer contracts (language) and/or auditing payer payments.
• Must be analytical, able to identify payment variance due to contract build or process errors, resolve payment issues, track & analyze payer information/policies.

Qualifications

• Experience working in Trizetto (Facets, Cognizant, Gateway EDI, QNXT) or equivalent tool preferred.
• Availity portal experience preferred.
• Salesforce case management experience preferred.
• AthenaOne software system experience preferred.
• Must comply with HIPAA rules and regulations.

Pay

The salary range for this role is $55,000.00–$60,000.00 in base pay, exclusive of any bonuses or benefits. This role is also eligible for an annual bonus targeted at 10%. The base pay offered will be determined based on relevant factors such as experience, education, and geographic location.

Benefits

• Medical, dental, and vision insurance.
• Life and pet insurance.
• 401K retirement plan.
• Paid time off.
• Other wellness programs.

Technical Requirements

For remote workers, a minimum internet speed of 5 MBPS for download and 3 MBPS for upload is required. Employees working remotely are eligible for expense reimbursement to offset this cost.