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. The Privia Platform is led by top industry talent and exceptional physician leadership, and consists of scalable operations and end-to-end, cloud-based technology that reduces unnecessary healthcare costs, achieves better outcomes, and improves the health of patients and the well-being of providers.

Under the direction of the Manager, Revenue Integrity and/or Sr. Director, 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. In addition, the Revenue Integrity Specialist is also responsible for addressing 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. This position works collaboratively with our operations consultants, RCM AR staff and management.

Primary Job Duties:

• - Reimbursement Audits: Conduct audits of payer processed claims to verify accurate reimbursement per payer contract agreements, government, and state rates.

  - Care Center Implementation Audits: Conduct post-implementation Care Center audits following the audit policy based on the number of providers on a 30/60/90/120 day schedule.

  - Strategic Initiatives: Assist the Manager, RI, in leading initiatives that drive efficiency and partnering internally and externally to deliver expected results (e.g., monthly market meetings with leadership, internal team meetings, and meetings with top commercial payers).

  - Decision Making & Communication: Make independent decisions regarding audit results and communicate these findings with appropriate teams, including contract negotiators, senior leaders, market leaders, and/or payers to ensure optimal revenue opportunity.

  - Escalation Management: Create, follow, and ensure adherence to approved escalation processes for timely issue resolution and completion of action plans.

  - Denial Management: Identify, monitor, and manage denial management trends. This includes working closely with Revenue Cycle Teams and payer representatives, and creating one-pagers/reference tools on payer policies.

  - System Support: Assist with Trizetto/Cognizant setup and fee schedule setup.

  - Operational Support: Work and address Salesforce cases along with AthenaOne tables.

  - Miscellaneous: Perform other duties as assigned, focused on key performance and department goals.

• High School Graduate preferred
• Advanced Microsoft Excel skills (ex: pivot table, VLOOKUP, sort/filtering and formulas)
• Payer enrollment experience/knowledge preferred 
• 3+ years payer contracts (language) and/or auditing payer payments
• Must be analytical, identify payment variance due to contract build or process errors, resolve payment issues, track & analyze payer information/policies.
• Experience working in Trizetto EOB resolve tool or equivalent use of contract management/software
• 3+ years of experience in a medical billing office preferred
• athenaOne software system experience is preferred
• Must comply with HIPAA rules and regulations

The salary range for this role is $55,000.00-$60,000.00 in base pay and exclusive of any bonuses or benefits (medical, dental, vision, life, and pet insurance, 401K, paid time off, and other wellness programs). 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.

All of your information will be kept confidential according to EEO guidelines.

Technical Requirements (for remote workers only, not applicable for onsite/in office work):

In order to successfully work remotely, supporting our patients and providers, we require a minimum of 5 MBPS for Download Speed and 3 MBPS for the Upload Speed. This should be acquired prior to the start of your employment. The best measure of your internet speed is to use online speed tests like https://www.speedtest.net/. This gives you an update as to how fast data transfer is with your internet connection and if it meets the minimum speed requirements. Work with your internet provider if you have questions about your connection. Employees who regularly work from home offices are eligible for expense reimbursement to offset this cost.

Privia Health is committed to creating and fostering a work environment that allows and encourages you to bring your whole self to work. We understand that healthcare is local and we are better when our people are a reflection of the communities that we serve. Our goal is to encourage people to pursue all opportunities regardless of their age, color, national origin, physical or mental (dis)ability, race, religion, gender, sex, gender identity and/or expression, marital status, veteran status, or any other characteristic protected by federal, state or local law.