Sr Mgr, Clearinghouse & EDI

The Sr Mgr, Clearinghouse & EDI owns the strategy, performance, and staffing of the clearinghouse and electronic claims function within a Durable Medical Equipment (DME) billing operation. Sets the direction for reducing front-end rejections, maintaining payer EDI connections at scale and driving measurable improvements in clean claim rate and daysto- transmit Leads a team of clearinghouse specialists and EDI analysts, partners with billing, coding, collections, and IT leadership, and represents clearinghouse operations in cross-functional and executive discussions Blends hands-on EDI/clearinghouse expertise with people leadership, vendor management, and data-driven decisionmaking JOB FUNCTIONS Owns end-to-end performance of the clearinghouse and EDI function, including clean claim rate, front-end rejection rate, days-to-transmit, and timely filing exposure report results and improvement plans to executive leadership Hires, trains, coaches, and manages a team of clearinghouse specialists and EDI analysts sets individual and team performance goals and conducts regular performance reviews Builds and continuously refines standard operating procedures, quality controls, and escalation paths for clearinghouse and EDI workflows across the department Serves as the primary escalation point for complex or high-dollar clearinghouse rejections, payer connectivity failures, and time-sensitive transmission issues Owns the vendor relationship with clearinghouse partners (e.

g. Waystar, Availity, Change Healthcare/Optum, Office Ally), including contract review, pricing, service-level performance, and platform roadmap discussions Leads root-cause analysis on recurring rejection and denial trends (eligibility, authorization, coding, EDI formatting) and drive cross-departmental corrective action with coding, intake, and collections leadership Oversees payer EDI enrollment, ERA/EFT setup, and re-credentialing across the payer mix, prioritizing new payer onboarding and problem accounts Partners with IT and billing system administrators on clearinghouse integrations, claim scrubber logic, system upgrades, and EDI file testing/validation Monitors regulatory and payer EDI requirement changes (X12 standard updates, CMS electronic submission mandates, payer-specific edits) and lead the team's readiness for compliance deadlines Builds and presents regular performance dashboards and trend reporting for executive and operational stakeholders, including town hall or leadership-meeting readouts Manages departmental budget items related to clearinghouse licensing, staffing, and vendor costs Ensures ongoing HIPAA compliance and PHI handling standards across the clearinghouse function Supports RFP responses, payer audits, and due diligence requests requiring clearinghouse or EDI performance data Champions process improvement and automation opportunities to reduce manual rework and scale the function with claim volume growth Education Bachelor's Degree in healthcare administration, business, or a related field preferred equivalent experience considered in lieu of degree, Required Work Experience 5+ years of progression in medical billing/revenue cycle operations, including clearinghouse and EDI management DME (durable medical equipment) billing experience strongly preferred 2+ years of direct people management, including hiring, coaching, and performance management Demonstrated management of vendor relationships and contract/service-level performance DME billing platform (e.

g. Brightree, Care. Tend, TIMS), required evaluating or implementing new billing/clearinghouse systems, a plus Knowledge, Skills, and Abilities Deep working of clearinghouse platforms (Waystar, Availity, Change Healthcare/Optum, Office Ally) and EDI transaction sets (837, 835, 270/271, 276/277) Strong understanding of Medicare DMEPOS billing rules, HCPCS Level II coding, and payer-specific claim edit requirements Strong analytics to translate rejection/denial data into actionable strategy advanced Excel, required communicate performance data and recommendations to executive stakeholders, including experience with presentations or town hall reporting Working understanding of HIPAA regulations and X12 EDI compliance standards Strong written and verbal communication comfortable leading cross-functional initiatives with coding, collections, IT, and payer-facing teams