Director Billing Operations Jobs in Rhode Island

Billing & Authorizations Specialist – Medical & Home Care

In Home Wellcare, a licensed home care agency in Rhode Island, is growing quickly and we're looking for the right person to join our team. This is a great opportunity for someone with billing experience who wants to be part of a mission-driven company, get exposure to both home care and medical billing, and grow with a supportive team.

This is an on-site position, not remote. It's not an entry-level role - the person in this seat needs direct experience with medical and/or home care billing and prior authorization work, and needs to be comfortable working across multiple insurance portals, billing systems, and EVV requirements at the same time.

Professional · Ethical · Reliable · Compassionate

Every role at In Home Wellcare is held to these same core values, and this one is no exception:

• Professional: Show up on time, look polished, keep personal issues at home. Proper dress, punctuality, good conduct.
• Compassionate: Care for people as if they were family. Love what you do. Be a helper. Genuine concern for patient welfare.
• Reliable: People can depend on you. Do what you say you will do. Show up for scheduled shifts. Follow through.
• Ethical: Do the right thing, even when no one is watching. Honest interactions, transparent communication.

Reporting Line

This position reports directly to the Director of Operations. Day-to-day coordination happens closely with the Scheduling Coordinators and the Operations Supervisor, since authorization status and eligibility directly affect what can be scheduled and billed.

Position Summary

The Billing & Authorizations Specialist owns the full billing lifecycle: eligibility verification, prior authorization tracking, EVV oversight, claims submission, remittance reconciliation, and denial resolution. Because client coverage can change without notice - including transitions to Neighborhood INTEGRITY for Duals - daily eligibility checks are essential to prevent unauthorized services and unpaid claims.

You'll be working with:

• Axxess – scheduling, EVV, claim generation
• Inovalon – clearinghouse for claims submission, exception review, and remittance
• Sandata Aggregator – EVV visit review and exception checking
• NaviNet & RI Medicaid Provider Portal – eligibility and authorization status
• Neighborhood Health Plan of RI (NHPRI) portal – authorization entry and status

Claims are billed daily for the prior day's visits and released mid-week to give EVV data time to sync and avoid unnecessary suspensions - never same-day.

Key Responsibilities

• Eligibility Verification – Run weekly eligibility checks through Inovalon and monthly manual checks through the Medicaid Provider Portal and NaviNet. For NHPRI clients, cross-reference LTSS status directly on the RI Medicaid Providers Portal and flag upcoming renewals to case managers and clients before they lapse.
• Prior Authorization Management – Track authorization effective/expiration dates and authorized hours; renew before they lapse; prevent service gaps.
• EVV Oversight – Check Axxess for completed tasks and signatures, then check the Sandata Aggregator for EVV exceptions before billing. Confirm a shift was actually assigned and worked before billing it.
• Claims Submission – Generate and verify claims in Axxess, check Inovalon's Exception Center, then release claims - timed to avoid EVV suspensions, never billed same-day as the visit.
• Billing Code Accuracy – Use correct HCPCS codes, modifiers, and whole-number units (S5125 – CNA, S5130 – Homemaker, T1001 – Nurse Visit, plus modifiers UH, UJ, TV, U1, and the U9 Priority 1 modifier).
• Denial & Underpayment Management – Reconcile remittance against billed claims, resolve denials and underpayments, and work within each payer's specific timely filing, adjustment, reconsideration, and appeal windows (Gainwell and NHPRI have different processes and deadlines).
• Private Pay Billing – Support intake and billing for private pay clients under agency rate and payment policies.
• Document Filing – Maintain client folders per the agency's three-tab filing system.
• Communication & Coordination – Serve as first backup to the Operations Manager for reviewing new referrals for family/household caregiver relationships when needed.

Qualifications

• Minimum 3 years of experience in medical or home care billing, claims, and prior authorization workflows.
• Proficiency in Axxess, Inovalon, NaviNet, the RI Medicaid Provider Portal, and ideally the NHPRI portal.
• Comfortable managing multiple claims, authorizations, and payer-specific deadlines at once.
• Strong attention to detail - able to catch a billing discrepancy before it becomes a denial.
• Must work on-site in Providence, RI (not remote).
• Bilingual (Spanish/English) strongly preferred.

How Success Is Measured

• Claims go out on schedule, with no backlog beyond one billing cycle.
• Prior authorizations are renewed before they expire.
• Eligibility verification is completed on the required weekly and monthly schedule.
• Denials are worked and resolved within one billing cycle.
• Coordinator-flagged authorization or eligibility issues are resolved within 48 hours.

Schedule

Full-time, on-site.

Benefits

• Medical coverage available after 90 days, subject to plan eligibility and annual open enrollment.
• Paid Time Off (PTO), per standard company policy.
• Opportunities for professional growth within the organization.