Revenue Cycle & Claims Operations Lead

Porter is hiring a Revenue Cycle & Claims Operations to join our Team! Porter combines the power of analytics with the power of care. Porter is a leading healthcare IT and services platform for care and coverage coordination that optimizes outcomes and member experience. We deliver understanding, compassion, information, and peace of mind for your members. Driven by robust AI analytics, Porter’s Care Guide team helps the member navigate the healthcare delivery system, secures the right support for each member’s specific needs, and directs Porter’s team of expert clinicians to perform comprehensive in-home assessments, complete with lab and diagnostic testing. By coordinating the complexities of each unique care journey, Porter helps close the gaps with the largest impact on quality measures, total cost of care, risk adjustment, and member experience. ABOUT THE ROLE Our organization operates in a payer-contracted services model — including delegated services, in-home assessments, HEDIS gap closure, and risk adjustment visits — rather than traditional fee-for-service care. Our billing patterns vary by payer and may include “penny claims” for encounter reporting paired with separate plan invoicing, or full-cost claims billed at the full contracted (allowable) rate. Our EMR/RCM platform, Athena, is built around traditional fee-for-service economics: maximizing collections, flagging low-dollar claims as errors, and defaulting to standard allowable-amount and co-insurance logic. This creates a persistent structural mismatch with our billing model. We are hiring a Revenue Cycle & Claims Operations Lead to own this problem end-to-end: to understand our payer contracts and billing models deeply, to configure and manage Athena as effectively as the platform allows, to build the reporting infrastructure needed to see what's actually happening to our claims, and to make a clear, well-supported recommendation on whether our long-term path is continued mitigation within Athena or migration to a different platform. KEY RESPONSIBILITIES Athena Configuration & Payer Alignment Serve as the primary internal owner of Athena claim edit rules, hold queues, and workflow configuration as they relate to our non-FFS billing model. Partner directly with Athena's professional services / support team to build and maintain custom rules that suppress inappropriate low-dollar (“penny claim”) edits and prevent unwanted allowable-amount or co-insurance recalculation on contracts where the full billed amount is the contracted rate. Translate payer contract terms (rate structures, encounter-reporting requirements, invoicing arrangements) into correct system configuration. Maintain a living documentation set of every custom rule, workaround, and configuration decision made in Athena, including rationale and payer applicability. Claims Operations & Oversight Ensure claims are reaching payers as intended and reconcile discrepancies between what was submitted, what was accepted, and what was paid or invoiced. Identify and clear inappropriate Athena holds; distinguish true data/coding issues from false positives generated by FFS-oriented logic. Track and resolve partial payments, particularly where Athena's allowable-amount logic conflicts with contracted full-payment terms. Oversee the separate plan-invoicing process for encounter/penny-claim arrangements, ensuring invoices reconcile against submitted encounters. Reporting & Analysis Design and maintain recurring reports covering: claim submission status, current holds and aging, partial payment / underpayment tracking, and payer-specific exception trends. Direct and review the work of the Billing & Claims Analyst in building and running these reports. Surface patterns (e.g., a hold type recurring across many claims for one payer) and use them to drive systemic fixes rather than one-off corrections. Strategic Recommendations Lead a structured 90-day assessment of Athena's fit for our billing model (see companion sc…