Revenue Integrity Specialist

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.