This role ensures reimbursement transactions are accurately reconciled, properly posted, supported, and operationally resolved across Commercial, Workers' Compensation, Personal Injury, and patient-pay revenue streams. The Revenue Integrity & Payment Reconciliation SME partners with Revenue Operations, Revenue Recovery & Resolution, Finance, Payer Relations, and NikoHealth enrollment resources to improve cash application, reduce manual payment processing, and strengthen financial controls.
Critical Competencies- Financial Reconciliation Expertise: Strong knowledge of claim-to-cash reconciliation, cash application, payment allocation, deposits, credits, refunds, adjustments, write-offs, unapplied cash, and financial exception resolution.
- Revenue Cycle & Reimbursement Knowledge: Comprehensive understanding of healthcare revenue cycle operations, reimbursement workflows, payer behavior, remittance processing, and the financial relationships among claims, payments, account balances, and adjustments.
- Remittance & Payment Processing: Ability to interpret ERA and paper remittance activity, validate payment-posting accuracy, investigate missing or mismatched remittances, and identify posting defects or allocation issues.
- ERA/EFT Workflow Coordination: Experience identifying electronic-payment opportunities, initiating ERA/EFT workflows, coordinating payer and internal stakeholders, tracking enrollment barriers, and validating successful activation.
- Analytical Thinking & Exception Management: Ability to investigate complex financial discrepancies, identify root causes and trends, quantify operational impact, prioritize exceptions, and drive issues through resolution.
- Process Improvement & Operational Controls: Ability to identify manual or inefficient payment workflows, strengthen reconciliation controls, support automation and system optimization, and improve audit readiness and financial accuracy.
- Cross-Functional Collaboration & Accountability: Strong ability to coordinate across Revenue Operations, Finance, Payer Relations, Contracting, clearinghouses, and enrollment resources while maintaining clear ownership, documentation, escalation, and follow-through.
Essential Duties and Responsibilities Financial Reconciliation Operations
- Reconcile payments, remittances, deposits, credits, refunds, adjustments, write-offs, and posted balances.
- Investigate differences among claims, remittances, deposits, posted payments, and account balances.
- Validate payment-posting activity for accuracy, completeness, and appropriate allocation.
- Research and resolve unapplied cash, unidentified payments, duplicate postings, and unsupported adjustments.
- Maintain reconciliation workpapers, supporting documentation, and audit trails.
- Support month-end reconciliation activities and operational financial reporting.
ERA and EFT Enrollment Support and Workflow Activation
- Identify payers, carriers, TPAs, and reimbursement sources using paper checks, paper remittance advice, or other manual payment workflows.
- Monitor payment and remittance activity to identify opportunities for ERA and EFT enrollment.
- Initiate and trigger the appropriate operational workflow when an ERA or EFT opportunity is identified.
- Coordinate with Revenue Operations, NikoHealth enrollment resources, Payer Relations, Contracting, Finance, clearinghouses, and other stakeholders to ensure opportunities are reviewed and actioned.
- Maintain an inventory of ERA and EFT opportunities, required documentation, assigned owners, status, barriers, and completion dates.
- Track open enrollment requests and escalate unresolved operational barriers.
- Support stakeholders with payer information, enrollment documentation, and payment-pattern evidence.
- Validate that newly activated ERA and EFT workflows are producing expected remittance and payment activity.
- Monitor post-implementation performance and identify remaining manual payment workflows.
- Report paper-check volume, paper-remittance volume, electronic-payment adoption, and open enrollment opportunities.
Revenue System Operations
- Partner with Revenue Operations to identify remittance, posting, and reconciliation inefficiencies.
- Collaborate with NikoHealth enrollment resources to initiate and support payer enrollment workflows.
- Provide payer, payment, and remittance information needed for enrollment review and implementation.
- Participate in operational testing and validation after enrollment activation.
- Maintain documentation of payment-delivery methods and remittance workflows.
- Identify workflow improvements that reduce manual posting and reconciliation effort.
Payment Posting and Remittance Validation
- Review ERA, paper remittance, EFT, paper check, and other payment activity for accuracy and completeness.
- Investigate payment allocation discrepancies, posting variances, and missing remittance information.
- Monitor payment-application trends and recurring posting defects.
- Validate adjustments and write-offs for appropriate application and supporting documentation.
- Support correction of identified posting errors and confirm completion.
Financial Exception Management
- Maintain reconciliation exception work queues, inventories, and tracking logs.
- Investigate unresolved financial transactions and discrepancies affecting account balances.
- Document the issue, root cause, financial impact, assigned owner, next action, and resolution status.
- Escalate unresolved, high-risk, or recurring financial findings.
- Analyze exception trends and recommend controls or workflow improvements.
Reporting, Analytics, and Continuous Improvement
- Develop and maintain reconciliation reports, enrollment trackers, and operational dashboards.
- Track unapplied cash, posting exceptions, remittance issues, reconciliation aging, and unresolved variances.
- Quantify the operational and financial impact of reconciliation issues and manual payment workflows.
- Identify opportunities to automate payment, remittance, cash-application, and reconciliation processes.
- Support workflow standardization, documentation, NikoHealth optimization, and continuous improvement initiatives.
- Provide timely, accurate, and decision-ready reporting to department leadership.
Minimum Qualifications
- Associate or bachelor's degree in accounting, Finance, Business Administration, Healthcare Administration, Revenue Cycle Management, or a related field, or an equivalent combination of education and directly related experience.
- Five or more years of healthcare revenue-cycle, reconciliation, payment-posting, cash-application, accounts-receivable, billing, or financial-operations experience.
- Demonstrated knowledge of remittances, ERA processing, EFT workflows, payment posting, adjustments, write-offs, unapplied cash, and reconciliation principles.
- Experience investigating complex financial transactions and documenting supported resolutions.
- Advanced Microsoft Excel skills and experience maintaining reconciliation or operational tracking tools.
- Strong analytical, organizational, documentation, communication, and cross-functional coordination skills.
- Ability to work independently, manage competing priorities, and follow issues through resolution.
Preferred Qualifications
- DME/HME experience with revenue-cycles.
- NikoHealth or comparable healthcare revenue-cycle platform experience.
- ERA and EFT enrollment support or implementation experience.
- Healthcare finance, accounting, cash-application, or payment-posting experience.
- Clearinghouse and payer-portal experience.
- Power BI or advanced reporting experience.
- Revenue-cycle, healthcare-finance, accounting, Lean, or process-improvement certification.
Success will be measured against the following Key Performance Indicators (KPIs) once performance benchmarks and baseline expansions have been established. Financial Reconciliation
- Reconciliation accuracy rate
- Financial-exception resolution rate
- Reconciliation queue aging
Payment Automation
- ERA opportunities identified and initiated
- EFT opportunities identified and initiated
- Electronic-payment adoption
- Paper-check volume reduction
- Paper-remittance volume reduction
Operational Performance
- Enrollment workflow initiation timeliness
- Open enrollment opportunity aging
- Remittance-processing turnaround time
- Payment-posting turnaround time
Quality and Improvement
- Documentation completeness
- Post-activation validation completion
- Repeat reconciliation-defect reduction
- Workflow improvements implemented
- Manual reconciliation effort reduced
