Director of Billing & Revenue Cycle Optimization

Role Description

AmeriPharma is seeking a visionary, high-energy Director of Billing to lead our Revenue Cycle Management (RCM) department. This is not a "status quo" management role. We are looking for a strategic leader who treats billing as a science—someone who will "think outside the box" to test, refine, and optimize billing practices across both Medical Benefit (Part B/Major Medical) and Pharmacy Benefit (Part D/PBM) platforms. The ideal candidate has an expert-level understanding of U.S. commercial insurance landscapes and a relentless drive to ensure every clinical service, supply, and medication we provide is captured, coded, and reimbursed at its maximum legitimate value.

Key Responsibilities

• Dual-Channel Optimization: Oversee and integrate billing operations for both Medical Benefit (J-Codes, HCPCS, CPT codes) and Pharmacy Benefit (NCPDP standards) to ensure seamless revenue flow.
• Billing "Test & Learn" Lab: Proactively design and execute "test billing" scenarios to identify new revenue streams, optimize modifier usage (e.g., -JW, -JZ), and capture reimbursement for ancillary clinical services often overlooked in specialty pharmacy.
• Commercial Plan Expertise: Apply deep knowledge of U.S. commercial payor policies (Aetna, BCBS, UnitedHealthcare, Cigna, etc.) to navigate complex Prior Authorization (PA) requirements and site-of-care restrictions.
• Strategic Contract Alignment: Collaborate with the Contracting team to ensure billing practices align with specific network rates, including First Health and other specialized wrap networks.
• Workflow Innovation: Audit existing RCM workflows to eliminate bottlenecks. Implement automated solutions for claim scrubbing, denial management, and secondary payor billing.
• Compliance & Audit Readiness: Ensure all "outside the box" optimizations remain strictly compliant with OIG, HIPAA, and CMS guidelines, maintaining a "defendable" billing posture.
• KPI Leadership: Define and report on aggressive RCM metrics, including Days Sales Outstanding (DSO), Net Collection Rate, and Clean Claim Rate, specifically segmenting Medical vs. Pharmacy performance.

Qualifications

• Experience: Minimum 8–10 years of leadership in Specialty Pharmacy or Infusion RCM, with a proven track record of managing $100M+ in annual collections.
• Technical Mastery: Advanced expertise in Medical Benefit billing (CMS-1500/UB-04) and Pharmacy Benefit billing (NCPDP). You must understand the "why" behind the code.
• Market Intelligence: Comprehensive knowledge of national and regional commercial insurance reimbursement policies and "White Bagging/Brown Bagging" dynamics.
• Analytical Mindset: Proficiency in data analytics tools (Excel, PowerBI, or Tableau) to track the success of billing experiments and optimizations.
• Education: Bachelor’s degree in finance or healthcare administration, or related field (Master’s or CPC/CPB certification preferred).

Preferred Attributes

• The "Intrapreneur": You don't wait for instructions; you identify a gap in reimbursement and build a billing strategy to close it.
• Aggressive Advocate: You view a denial as a data point to be solved, not a final answer.
• Systems Thinker: Ability to work across departments (Clinical, Intake, and Sales) to ensure the documentation supports the billing innovation.

Technical Software Proficiencies

• Specialty Pharmacy Systems: PioneerRx or FrameworkLTC for high-volume prescription dispensing, clinical documentation, and automated reporting.
• Infusion & HME Billing: Brightree for managing complex home infusion workflows, medical benefit (Part B) claims, and digital document management.
• Revenue Cycle Tools: Experience with CPR+ (or its successors) for end-to-end infusion management, from intake and authorizations to final adjudication.
• Claims Clearinghouses: Proficiency in platforms like Waystar or Change Healthcare for claim scrubbing and real-time denial tracking.
• Data Analytics: Advanced use of Power BI or Tableau to build custom dashboards that track "test billing" success and LOB-specific collection trends.

Compensation & Performance-Based Bonus Structure

• Base Salary: Typically ranges from $150,000 to $200,000+ per year, depending on expert-level experience and track record with national commercial plans in California.
• Performance Bonus (Quarterly/Annual): A multi-factor scorecard designed to reward both operational excellence and financial growth.
• Net Collection Rate (NCR): Tiered bonus for maintaining an NCR above 95% across both medical and pharmacy benefits.
• Revenue Capture Innovation: A "milestone bonus" for each successfully implemented billing optimization (e.g., capturing a previously unbilled clinical service or supply) that results in a verifiable 5%+ increase in reimbursement for that service line.
• DSO Reduction: Incentives for reducing Days Sales Outstanding below a specific target (e.g., <45 days).
• Denial Rate Targets: Bonuses tied to keeping the initial denial rate below 5% through proactive "test billing" and claim scrubbing.

The "Optimizer" Mindset: Expectations for Innovation

We aren't just looking for a manager; we want an architect of revenue. The Director will be expected to:

• Test Billing Scenarios: Run small-batch test claims for new clinical codes or modifiers to verify payor response before a full rollout.
• Audit for Omissions: Periodically audit high-cost therapies to ensure every ancillary service—nursing visits, specialized supplies, and clinical monitoring—is billed and reimbursed.
• National Plan Advocacy: Use deep knowledge of commercial plan nuances (e.g., Aetna’s specific medical benefit requirements vs. UnitedHealthcare's) to customize billing rules by payor.