Senior Medical Biller

Senior Medical Biller (eClinicalWorks Required) Remote | Full-Time | Independent Physician Practice

About OptiClaim Business Solutions

OptiClaim Business Solutions LLP is a specialized healthcare revenue cycle management and staffing firm operating across India and U.S. markets. We partner with independent physicians and small-to-mid-size practices to build high-performance billing operations — from credentialing and coding through collections and compliance. We are currently expanding our U.S. client portfolio and seeking a seasoned RCM professional to take full ownership of a physician billing account.

Role Overview

We are seeking a Revenue Cycle Manager / Senior Medical Biller to lead the complete professional billing function for an independent physician practice operating across outpatient clinic, hospital, and skilled nursing facility (SNF) / nursing home settings.

This is not a supervisory-only role. The right candidate is a working RCM lead — someone who can independently manage charge entry, coding review, claim submission, AR follow-up, denial management, credentialing, and reporting, while building out a scalable billing department over time.

Strong, hands-on experience with eClinicalWorks (eCW) is mandatory. Candidates without eCW experience will not be considered.

Key Responsibilities

Revenue Cycle & Billing Operations

• Manage the full professional billing lifecycle: charge capture → charge entry → claim scrubbing → electronic claim submission → ERA/EOB posting → AR follow-up → denial management → collections
• Ensure timely and accurate claim submission for all service lines: primary care / outpatient clinic, hospital visits (inpatient and outpatient), nursing home / SNF visits, procedures, labs, and diagnostic interpretations
• Monitor accounts receivable (AR) aging, track days in AR, and resolve outstanding claims proactively
• Maintain clean claim rates and minimize denial rates through front-end and back-end billing controls
• Manage payer-specific billing rules, fee schedules, and contract terms for Medicare, Medicaid, and commercial payers

Coding & Documentation Review

• Review provider documentation and assign accurate CPT codes, ICD-10-CM diagnosis codes, and applicable modifiers
• Validate E/M level selection for office visits (99202–99215), hospital visits (99221–99223, 99231–99233), nursing home visits (99304–99310), and discharge services
• Ensure procedure coding compliance for in-office procedures, preventive services, lab orders, and diagnostic interpretations
• Identify documentation gaps and work directly with the provider to correct or addend clinical notes
• Maintain coding compliance with CMS guidelines, payer LCD/NCD policies, and OIG standards

eClinicalWorks (eCW) Billing Management

• Manage all billing workflows inside eClinicalWorks: charge entry, claim scrubbing, claim submission, and rejection workqueues
• Post insurance payments, patient payments, contractual adjustments, and write-offs
• Work claim edits and clearinghouse rejections through eCW and the integrated clearinghouse (e.g., Waystar, Change Healthcare)
• Run and analyze billing reports, productivity reports, and payer performance reports inside eCW
• Maintain and update fee schedules, payer setups, referring provider data, and place-of-service configurations
• Optimize billing workflows and workqueue management to improve throughput and reduce lag time

Payer Relations & AR Follow-Up

• Conduct proactive AR follow-up on all outstanding claims across Medicare, Medicaid (state), and commercial payers
• Use payer portals (Navinet, Availity, Emdeon, payer-direct portals) for real-time claim status, remittance review, and appeal submissions
• Manage denial root cause analysis (RCA) — identify patterns in denials by payer, denial reason code, and service type
• Write and submit formal appeals with supporting clinical documentation, medical necessity letters, and payer-specific appeal forms
• Track and resolve coordination of benefits (COB), timely filing, authorization, and medical necessity denials
• Maintain low AR days outstanding and report aging metrics to leadership on a regular cadence

Credentialing & Provider Enrollment

• Manage initial provider credentialing and re-credentialing with Medicare (PECOS), Medicaid (state MACs), and commercial health plans
• Maintain and update provider CAQH ProView profile and ensure attestation is current
• Complete payer enrollment applications, follow up on pending enrollments, and resolve enrollment-related billing holds
• Ensure provider is actively enrolled and linke