Revenue Integrity Specialist

Company Description

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.

Job Description

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. 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:

• Auditing 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 on a 30/60/90/120 post implementation/go-live date
• Assist the Sr. Manager, RI to lead 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 to timely issue resolution and completion of action plans.
• Identify, monitor and manage denial management trends. Work closely with our Revenue Cycle Teams, payer representatives and create one pagers/reference tools on payer policies.
• Assist with Trizetto/Cognizant setup, fee schedule setup
• Work and address Salesforce cases along with athenaOne tables
• Perform other duties as assigned focused on key performance and department goals

Qualifications

• Education: High School Graduate
• 3+ years of experience in a medical billing office required
• Google Sheets/ Microsoft Excel skills (ex: pivot table, VLOOKUP, sort/filtering and , formulas) required
• 3+ years payer contracts (language) and/or auditing payer payments required
• 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 (Facets, Cognizant, Gateway EDI, QNXT) or equivalent tool preferred
• Availity portal experience preferred
• Salesforce case management experience 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.

Additional Information

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 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.