Sr Mgr, Clearinghouse & EDI

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

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

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

Bachelor's Degree in healthcare administration, business, or a related field preferred equivalent experience considered in lieu of degree, Required

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

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, CareTend, TIMS), required evaluating or implementing new billing/clearinghouse systems, a plus

evaluating or implementing new billing/clearinghouse systems, a plus