Sr Mgr, Clearinghouse & EDI

The Sr Mgr, Clearinghouse & EDI owns the strategy, performance, and staffing of the clearinghouse and electronic claims function within aDurable 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 decision making

• 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 andteam 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 newpayer 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'sDegreein healthcare administration, business, or a related field preferred
  • equivalent experience considered in lieu of degree,Required

• 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

• 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

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled
Lincare is an equal opportunity employer, access and affirmative action employer. All qualified…