Lead Medical Biller & RCM

Job Description: Lead Medical Biller & RCM
Department: Revenue Cycle Management (RCM)
Reports To: CEO

Position Type: Full-Time

Job Summary
The Home Health & DME Billing Specialist is responsible for executing full-cycle billing operations across our Home Health, Durable Medical Equipment (DME), and Pharmacy business lines. This role balances standard commercial/government insurance collections with the strategic management of high-priority specialty accounts (including Cook County, University of Chicago, and Private Pay International patients).
By implementing industry-standard billing protocols (PDGM, NOA, SWO) and aggressively managing accounts receivable, the Specialist ensures maximum, compliant reimbursement and resolves legacy outstanding revenue.

Key Responsibilities
1. End-to-End Claim Management & Industry Protocols
• Clean Claim Submission: Prepare, scrub, and submit clean claims daily. Manage electronic transmissions (837I/837P) and execute specialized paper claim submissions (UB-04 for Home Health; CMS-1500 for DME) to Managed Medicare, Medicaid, and commercial payers.
• Home Health Compliance: Adhere strictly to the Patient-Driven Groupings Model (PDGM) guidelines. Monitor the 5-day regulatory window for Notice of Admission (NOA) submissions to avoid late-filing payment penalties. Ensure accurate HIPPS coding mapping.
• DME Compliance: Verify that all claims align with current CMS standard documentation requirements. Ensure a valid Standard Written Order (SWO) and Proof of Delivery (POD) are on file prior to billing. Stay updated on quarterly HCPCS Level II code and fee schedule modifications.
2. Denials, Appeals & ADR Management
• Audit Response (ADR): Serve as the primary responder to Additional Documentation Requests (ADRs), with a heavy focus on UnitedHealthcare and Blue Cross Blue Shield. Efficiently extract, compile, and audit clinical records (including Physician Orders, History & Physicals [H&Ps], and clinical visit notes) to fulfill audit deadlines.
• Appeals & Rejections: Review, troubleshoot, and aggressively appeal rejected or denied claims. Correct front-end clearinghouse rejections and draft clinical appeal letters to secure maximum reimbursement.
3. Accounts Receivable (AR) & Payment Posting
• AR Tracking & Collections: Maintain and manage the aging AR report. Routinely follow up on outstanding claims with payers to identify payment bottlenecks and prevent claims from exceeding Timely Filing Limits.
• Payment Posting: Accurately post insurance reimbursements from Electronic Remittance Advices (ERAs/EOBs) and direct patient payments, keeping financial ledgers reconciled.
4. Prebilling & Workflow Synergy
• Prebilling Optimization: Regularly update and audit the prebilling list. Collaborate with internal teams to ensure clinicians complete documentation in a timely manner, allowing claims to flow to the billing stage rapidly.
Specialty Account Portfolios
This position commands complete ownership over the following specialized and uninsured billing tracks:
• Cook County (Uninsured Programs): Manage and bill dedicated tracks for Cook County, including DME, Pharmacy (utilizing the Niko Health platform), and Nursing/Palliative Home Health care.
• Cook County Back-Billing: Lead revenue recovery efforts by analyzing, troubleshooting, and executing back-billing protocols for legacy, unpaid Cook County accounts.
• University of Chicago (Uninsured DME): Process, bill, and monitor DME claims designated under the University of Chicago uninsured workflows.
• International Patients (Private Pay DME): Coordinate specialized itemized billing, statement generation, and payment collections for international private pay accounts.

Qualifications & Skills
• Experience: 3+ years of medical billing experience, with specific exposure to Home Health (OASIS/PDGM workflows) and/or DME billing.
• System Experience: Proficiency with electronic billing clearinghouses and EHRs. Direct experience with Niko Health is highly preferred.
• Regulatory Knowledge: Deep understanding of CMS guidelines, UB-04 and CMS-1500 coding, prior authorization matrixes, and commercial insurance rules (particularly BCBS and UnitedHealthcare).
• Core Competencies: Strong analytical skills for AR auditing, excellent communication skills for resolving complex payer issues, and a proactive mindset for hunting down older, unpaid cash flow.
What Success Looks Like in This Role
• First-Pass Clean Claim Rate: Maintaining an industry-standard first-pass claim acceptance rate of 95% or higher.
• Days in AR: Significantly lowering the average Days in AR for the Cook County and University of Chicago portfolios.
• Audit Resolution: 100% compliance and timely submission rates on all United and BCBS ADR packets, preventing clawbacks or unnecessary revenue loss.