Medical Claims Billing Specialist - Case Management

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.

*This position is a hybrid full-time role that requires in office on Tuesdays and Thursdays at 1200 Binz St Suite 1490 Houston TX 77004. Mon, Wed, and Fri are typically work from home but subject to change for internal meetings, trainings, and conferences.*

Under the direction of the Sr. Manager of Revenue Cycle Management, the Medical Claims Billing Specialist - Case Management (AR Manager) is responsible for complete, accurate and timely processing of all designated claims, reviewing and responding to daily correspondence from physician practices in a timely manner, answering incoming SalesForce cases and providing information as requested or properly authorized. The Medical Claims Specialist will take steps necessary to resolve all claim issues or questions that escalate to the RCM team. Resolution of SalesForce cases and management of issues and the team resolving the cases is a key element in this role. 

Primary Job Duties:

• Denial management - investigating denial sources, resolving and appealing denials which may include contacting payer representatives

• Manage Salesforce Care Center inquiries 

• Analyze, escalate and report out on Care Center inquiry trends

• Makes independent decisions regarding claim adjustments, resubmission, appeals, and other claim resolution techniques

• Collaborate internal teams (Performance, Operations, Sales) as well as care center staff when appropriate

• Works closely with our Revenue Optimization team, to support efforts to ensure reimbursement is in line with payer contract agreements. Performs Denial analysis utilizing the Trizetto platform

• Work directly with practice consultants or physicians to ensure optimal revenue cycle functionality

• Drive toward achievement of department’s daily and monthly Key Performance Indicators (KPIs), requiring a team focused approach to attainment of these goals

• Other duties as assigned

• Education: High School diploma  

• Experience: 3+ years medical claims experience in a physician medical billing office

• Must understand the drivers of revenue cycle optimal performance and be able to investigate and resolve complex claims.

• Salesforce case management experience required

• Must understand Explanation of Benefit (EOB) statements

• Advanced Microsoft Excel skills (ex: pivot tables, VLOOKUP, sort/filtering, formulas) preferred
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• Must understand Explanation of Benefit (EOB) statements

• Google Suite experience preferred

• Athena EMR experience preferred 

• Must provide accessibility to private, quiet work space with high-speed internet to effectively work remotely for days not in the office

• Comfortable speaking in front of groups

• Excellent written and verbal communication

• Willingness to train and mentor other team members

• Self-starter with great time management skills

• Ability to work independently and multi-task in a fast paced environment

• Problem solver with good analytical skills and solution-oriented approach

• Independent decision maker with strong research skills

• Must comply with HIPAA rules and regulations 

The hourly range for this role is $24/hr - 26.45/ hr in base pay and exclusive of any bonus 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% based on performance in the role. The base pay offered will be determined based on relevant factors such as experience, education, and geographic location.

All 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.