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Sr Mgr, Clearinghouse & EDI

Lincare

  • Clearwater, FL
  • Today

    Highlights

    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. 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).

    Numbers & Facts

    LocationClearwater, FL

    Description

    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, CareTend, 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



                                                                          Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled

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