Director of Billing

AmeriPharma • Laguna Hills, CA

9d • $145,000 - $155,000 • Remote

About The Position

AmeriPharma Specialty Care is seeking a Director of Billing to lead and elevate billing operations across both the Medical Benefit (Part B and Major Medical) and Pharmacy Benefit (Part D and PBM) channels. This leader will own end-to-end professional billing performance for specialty pharmacy, home infusion, infusion suite (AIC), and complex therapy lines, ensuring every service, supply, and medication is captured, coded, and reimbursed accurately, completely, and in full compliance with payer and regulatory requirements.
The Director is accountable for first-pass clean claim performance, reimbursement integrity, denial prevention, and the operational discipline required to convert clinical activity into realized revenue. The role partners closely with Contracting, Intake, Pharmacy Operations, Clinical, and Compliance to ensure billing practices reflect current contract terms, payer policy, and documentation standards.

Requirements

• Minimum 8–10 years of progressive leadership in Specialty Pharmacy or Home Infusion Revenue Cycle, with demonstrated accountability for $100M or greater in annual collections.
• Advanced expertise in Medical Benefit billing (CMS-1500 and UB-04) and Pharmacy Benefit billing (NCPDP), with deep working knowledge of CPT, HCPCS, J-Codes, ICD-10, and modifier application across infusion, injectable, and specialty drug categories.
• Comprehensive understanding of national and regional commercial reimbursement policy, government payer rules, prior authorization frameworks, and specialty distribution dynamics.
• Proficiency in data analytics platforms (Power BI, Tableau, Superset, or equivalent) to monitor performance, identify trends, and substantiate reimbursement decisions.
• Bachelor’s degree in Finance, Healthcare Administration, Business, or related field.

Nice To Haves

• Master’s degree or professional certification (CPC, CPB, CRCR, or equivalent) preferred.

Responsibilities

• Direct billing operations across Medical Benefit (J-Codes, HCPCS, CPT, CMS-1500, UB-04) and Pharmacy Benefit (NCPDP) channels, ensuring coordinated revenue capture for therapies billable under either benefit.
• Lead, mentor, and develop the professional billing staff across specialty pharmacy and infusion lines. Establish clear performance standards, training plans, and career pathways.
• Audit and refine billing workflows to remove rework, reduce touch points, and shorten the cycle from service date to clean claim submission. Implement automation where appropriate for claim edits, eligibility verification, and secondary claim routing.
• Oversee pharmacy and professional medical cash posting operations, ensuring accurate, timely, and fully reconciled posting of payments, adjustments, and remittances across both benefit channels. Maintain controls that support clean AR aging, accurate reporting, and audit readiness.
• Conduct structured reviews of code selection, modifier application (including JW, JZ, and infusion-specific modifiers), units billed, and place-of-service designations to ensure each claim accurately reflects the service provided and the payer’s coverage policy.
• Establish formal pre-billing audit and validation protocols, including small-volume claim validation cycles to confirm payer acceptance of new codes, modifiers, or product NDCs before broad submission. All validation activity is documented, evidence-based, and grounded in published payer policy and contract terms.
• Ensure all billable components of complex therapies — including nursing administration, supplies, clinical monitoring, and pharmacist clinical services — are documented and submitted in accordance with payer policy and AmeriPharma contracts.
• Treat every denial as an actionable data point. Lead structured root-cause analysis, drive upstream corrections in intake and clinical documentation, and reduce avoidable denial volume cycle over cycle.
• Apply current working knowledge of national and regional commercial payer policy (Aetna, BCBS plans, UnitedHealthcare, Cigna, Humana, and others) to navigate prior authorization requirements, site-of-care policy, white-bagging and brown-bagging dynamics, and benefit determination rules.
• Partner with Contracting to ensure billing practices reflect current network rates and terms, including specialty wrap networks such as First Health, and to surface contract gaps or interpretation issues that affect realized reimbursement.
• Ensure Medicare Part B, Medicare Part D, Medicaid (FFS and MCO), and dual-eligible billing follows current CMS and state-specific guidance.
• Ensure billing practices remain fully compliant with OIG, HIPAA, CMS, USP, and state pharmacy and Medicaid requirements. All optimization activity is documented, defensible, and supported by published payer policy and contract terms.
• Lead internal and external billing audit responses, including payer audits, OIG inquiries, and Medicaid reviews. Maintain documentation standards that withstand third-party review.

Benefits

• Competitive pay and generous compensation structures
• Full benefits package including medical, dental, vision, and life that fits your lifestyle and goals
• Employee assistance program to assist with mental health, legal questions, financial counseling, and more!
• 401k program
• Comprehensive PTO and sick leave options
• Opportunities for growth and advancement
• Casual Fridays

What This Job Offers

• Job Type: Full-time
• Career Level: Director