Sr Mgr, Clearinghouse & EDI

Job DescriptionThe 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-transmitLeads 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 discussionsBlends hands-on EDI/clearinghouse expertise with people leadership, vendor management, and data-driven decisionmakingJOB FUNCTIONSOwns 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 leadershipHires, trains, coaches, and manages a team of clearinghouse specialists and EDI analysts sets individual and team performance goals and conducts regular performance reviewsBuilds and continuously refines standard operating procedures, quality controls, and escalation paths for clearinghouse and EDI workflows across the departmentServes as the primary escalation point for complex or high-dollar clearinghouse rejections, payer connectivity failures, and time-sensitive transmission issuesOwns 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 discussionsLeads 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 leadershipOversees payer EDI enrollment, ERA/EFT setup, and re-credentialing across the payer mix, prioritizing new payer onboarding and problem accountsPartners with IT and billing system administrators on clearinghouse integrations, claim scrubber logic, system upgrades, and EDI file testing/validationMonitors regulatory and payer EDI requirement changes (X12 standard updates, CMS electronic submission mandates, payer-specific edits) and lead the team's readiness for compliance deadlinesBuilds and presents regular performance dashboards and trend reporting for executive and operational stakeholders, including town hall or leadership-meeting readoutsManages departmental budget items related to clearinghouse licensing, staffing, and vendor costsEnsures ongoing HIPAA compliance and PHI handling standards across the clearinghouse functionSupports RFP responses, payer audits, and due diligence requests requiring clearinghouse or EDI performance dataChampions process improvement and automation opportunities to reduce manual rework and scale the function with claim volume growthJob RequirementsEducationBachelor's Degree in healthcare administration, business, or a related field preferred equivalent experience considered in lieu of degree, RequiredWork Experience5+ years of progression in medical billing/revenue cycle operations, including clearinghouse and EDI management DME (durable medical equipment) billing experience strongly preferred2+ years of direct people management, including hiring, coaching, and performance managementDemonstrated management of vendor relationships and contract/service-level performanceDME billing platform (e.g. Brightree, CareTend, TIMS), required evaluating or implementing new billing/clearinghouse systems, a plusKnowledge, Skills, and AbilitiesDeep 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 requirementsStrong analytics to translate rejection/denial data into actionable strategy advanced Excel, requiredcommunicate performance data and recommendations to executive stakeholders, including experience with presentations or town hall reportingWorking understanding of HIPAA regulations and X12 EDI compliance standardsStrong written and verbal communication comfortable leading cross-functional initiatives with coding, collections, IT, and payer-facing teamsJob DetailsJob Type: Full-timeCategory: Billing