Billing and Claims Analyst

ABOUT THE ROLE

Our organization operates in a payer-contracted services model — delegated services, in-home assessments, HEDIS gap closure, and risk adjustment visits — billed through Athena in a mix of penny-claim/encounter-reporting and full-cost claim arrangements. Because Athena's default logic is built for traditional fee-for-service billing, our claims regularly get flagged, held, or underpaid in ways that don't reflect actual problems.

We're hiring a Billing & Claims Analyst to be the day-to-day set of eyes on our claims: tracking what's been submitted, what's stuck, what's been paid, and what's been invoiced separately — and flagging patterns to the Revenue Cycle & Claims Operations Lead so they can be fixed at the source.

KEY RESPONSIBILITIES

• Build and maintain recurring reports in Athena covering claim submission status, hold/edit queues, and payment status.
• Reconcile claims sent to payers against invoices sent separately for encounter/penny-claim arrangements, confirming amounts match and nothing has fallen through the cracks.
• Track partial payments and underpayments, flagging cases where Athena has applied a standard allowable amount or co-insurance deduction that conflicts with the actual contracted rate.
• Maintain claim-aging reports so nothing sits in a hold queue unnoticed.

Claims Monitoring & First-Line Troubleshooting

• Monitor daily/weekly claim submission activity to confirm claims are actually reaching payers, not just leaving Athena.
• Review current holds in Athena, distinguish routine/expected holds from ones tied to our known penny-claim or allowable-amount issues, and route the latter for escalation.
• Perform basic first-line correction on claims where the fix is known and documented, escalating anything new or ambiguous.

Support for Systemic Fixes

• Document recurring issues (e.g., a specific hold code affecting a specific payer or claim type) with enough detail for the Operations Lead to escalate to Athena or the payer.
• Support testing and validation whenever a new custom rule or workflow change is implemented in Athena, confirming it behaves as expected across a sample of claims.
• Contribute claim-level detail to the 90-day Athena assessment and any future EMR evaluation.

REQUIRED QUALIFICATIONS

• 1–3+ years of experience in medical billing, claims processing, or revenue cycle operations.
• Working proficiency in Athena (or comparable EMR/RCM system) — running reports, navigating claim status and hold queues, and pulling claim-level detail.
• Strong Excel skills (pivot tables, VLOOKUP/XLOOKUP, basic reconciliation building); SQL or other data-query experience is a plus but not required.
• High attention to detail and comfort with repetitive reconciliation work — this role lives in the data, not just the summary.
• Clear written communication for documenting issues and escalations.

PREFERRED QUALIFICATIONS

• Prior exposure to value-based care, risk adjustment, HEDIS, or delegated/capitated billing models.
• Experience with encounter data reporting or non-standard (non-FFS) claim types.
• Familiarity with payer portals for claim status verification.