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Porter is a healthcare IT and services platform specializing in care and coverage coordination. The company uses AI-driven analytics to help members navigate the healthcare system, coordinate complex care journeys, and optimize outcomes across quality measures, total cost of care, risk adjustment, and member experience.
The Billing & Claims Analyst role is responsible for day-to-day oversight of Porter's claims operations. Porter operates in a payer-contracted services model (delegated services, in-home assessments, HEDIS gap closure, risk adjustment visits) billed through Athena using 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, claims regularly get flagged, held, or underpaid in ways that don't reflect actual problems. This analyst will be the primary set of eyes on claims tracking, monitoring, and troubleshooting.
Key responsibilities include:
**Reporting & Reconciliation:** 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 to ensure nothing sits in a hold queue unnoticed.
**Claims Monitoring & First-Line Troubleshooting:** Monitor daily/weekly claim submission activity to confirm claims are reaching payers. Review current holds in Athena, distinguish routine/expected holds from ones tied to 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
- 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
