Manager, Front End Revenue Cycle

Responsibilities

Eligibility Management

• Own the end-to-end member eligibility process — from receipt of client eligibility files through verification of active insurance coverage in Athena Health
• Define and enforce client eligibility file completeness standards; establish intake SLA with Client Success for incomplete or missing demographic and insurance data
• Implement and manage real-time eligibility (RTE) verification (using ANSI X12 270/271) transactions to confirm active coverage before claims are submitted
• Develop and maintain a reconciliation process to ensure all active members in Zuora have corresponding verified records in Athena
• Identify and resolve eligibility discrepancies, retroactive terminations, and coverage changes before they result in denied claims or revenue loss
• Monitor eligibility-related denial trends and implement upstream controls to reduce recurrence

Claims Entry & Submission Integrity

• Oversee the accuracy and completeness of claims preparation and entry across all Virta Health products — Diabetes Reversal, Diabetes Management, and Sustainable Weight Loss
• Ensure all claims are coded correctly and submitted within payer-specific timely filing windows
• Monitor claim submission lag — the time between billing period close and claim submission — and establish benchmarks to reduce exposure
• Work with Engineering to improve the flow of billing trigger data from Spark into Athena, reducing manual intervention in claims entry
• Implement pre-submission claim scrubbing processes to improve clean claim rates and reduce first-pass rejections
• Maintain working knowledge of CPT, HCPCS, and ICD-10 coding requirements relevant to Virta Health's digital health and value-based care model

Provider Credentialing

• Manage provider and program credentialing and payer enrollment for all applicable Virta Health providers, locations, and product lines
• Ensure all providers are enrolled with payers prior to service delivery to prevent claim denials related to credentialing status
• Maintain a credentialing tracking system with defined renewal timelines, expiration alerts, and re-credentialing workflows
• Coordinate with Legal, HR, and Clinical Operations on provider onboarding and payer network participation requirements

Team Leadership & Development

• Recruit, onboard, and develop front-end RCM staff including eligibility specialists, claims entry staff, and credentialing coordinators
• Establish role-specific SOPs, training programs, and performance expectations for all front-end positions
• Conduct regular performance reviews and provide coaching to develop staff competency in eligibility verification, coding, and claims entry
• Partner with the Manager/Director of Operational Effectiveness on reporting and process improvement initiatives affecting front-end functions

90 Day Plan

• Eligibility file completeness rate: 100% of required fields present before member activation
• RTE verification rate: 100% of members verified via 270/271 before claim submission
• Clean claim rate: >95% claims accepted on first submission
• Claim submission lag: Claims submitted within 5 business days of billing period close
• Credentialing current rate: 100% of active providers enrolled with applicable payers
• Eligibility denial rate (CO-27): Reduction to

Must-Haves

• 5+ years of revenue cycle management experience with a focus on front-end functions — eligibility, claims entry, and/or credentialing
• Strong working knowledge of ANSI X12 EDI transactions including 270/271 (eligibility), 837 (claims), and 835 (remittance)
• Experience with Athena Health or comparable practice management/claims system
• Demonstrated ability to manage cross-functional relationships with Client Success, Engineering, and clinical teams
• Experience in healthcare technology, digital health, or value-based care environments preferred
• Demonstrates a proactive use of AI tools to improve individual output and efficiency