Job Function Summary
The Credentialing & Licensing Specialist is responsible for overseeing all initial and ongoing payer enrollment, credentialing, recredentialing, revalidation, and regulatory reporting activities necessary to establish and maintain the Company's participation and good standing with government-funded healthcare programs, managed care organizations, and commercial insurance payers. This position ensures compliance with all applicable federal, state, contractual, and payer-specific requirements; obtains, renews, and maintains all required business and operational licenses and registrations, including Board of Pharmacy, HME/DMEPOS, facility, business, and Secretary of State filings; and manages the implementation and ongoing maintenance of payer information within the Company's patient management and billing systems. The role serves as a critical liaison across departments and external stakeholders to ensure accurate payer setup, operational readiness, uninterrupted reimbursement, corporate compliance, and continuous regulatory compliance across all jurisdictions in which the Company operates.
Major Areas of Accountability
- Process and complete payer enrollment, revalidation, credentialing, and re-credentialing applications for Medicare, Medicaid, managed care organizations, commercial health plans, and other contracted payers; monitor application status and perform follow-up to ensure timely participation and reimbursement.
- Manage administrative functions for all government, commercial, and managed care payer accounts, including portal administration, demographic maintenance, ownership updates, licensure updates, revalidations, and enrollment record management.
- Manage administrative functions related to company licenses, state DME permits, supplier registrations, business licenses, and accreditation requirements, including renewals, documentation, and compliance tracking.
- Maintain Medicare supplier enrollment records, including PECOS-related documentation, revalidations, site information, ownership updates, and compliance with Medicare supplier standards.
- Prepare and submit ownership disclosures, changes of information, corporate structure updates, adverse action disclosures, and other regulatory filings required by federal healthcare programs, state Medicaid programs, and commercial payers.
- Set up and maintain EDI enrollments, electronic claims submission processes, clearinghouse relationships, payer IDs, and related payer connectivity requirements.
- Process and complete any electronic funds transfer (EFT) applications and electronic remittance advice (ERA) applications.
- Maintain and update any contract-related reference sheets, job aids, tracking sheets, and reference guides as well as distribute any companywide internal FYI communications regarding new payer contracts or policy changes.
- Maintain reimbursement fee schedules and payer-specific pricing information within company systems; process annual and periodic updates for Medicare, Medicaid, commercial, and contracted payer reimbursement methodologies.
- Maintain and communicate contracted payer participation status to internal stakeholders, referral sources, physician partners, distributors, vendors, and other business partners.
- Maintain and update any contract-related reference sheets, job aids, tracking sheets, and reference guides as well as distribute any companywide internal FYI communications regarding new payer contracts or policy changes.
- Aid and assist the Market Access Team with any applications or credentialing initiatives for the commercial contracts and health plans.
- Maintain compliance with Medicare supplier standards, accreditation requirements, Federal and State regulations, payer requirements, and company policies and procedures.
- Comfort Medical employees are required to conduct business to the highest ethical and professional standards; comply with applicable laws and regulations, the MedTech Code of Conduct, and company policies.
- Other job duties as assigned.
Basic Qualifications
- High school diploma or equivalent required; Associate degree preferred.
- 3-5 years of experience in healthcare administration, payer enrollment, credentialing, licensing, provider relations, or related support functions.
- Strong organizational skills with the ability to manage multiple priorities and meet deadlines.
- Proficiency in Microsoft Office Suite and other business-related software applications.
- Strong attention to detail and data entry accuracy.
- Ability to interpret instructions, policies, and payer requirements and complete tasks independently.
- Excellent verbal and written communication skills.
- Ability to adapt to changing priorities and work effectively in a fast-paced environment.
- Strong time management, problem-solving, and decision-making skills.
- Ability to work both independently and as part of a team.
Preferred Qualifications
- Associate degree in Healthcare Administration, Business Administration, or a related field.
- Experience with Medicare, Medicaid, commercial payers, or healthcare network operations.
- Knowledge of payer enrollment, credentialing, contracting, licensing, or regulatory compliance processes.
- Experience with payer portals, EFT/ERA enrollment, or provider/supplier data management.
- Familiarity with HIPAA and healthcare privacy requirements.
- Experience in the Durable Medical Equipment (DME) industry preferred.
Comfort Medical provides an extensive selection of name brand catheter and ostomy supplies to thousands of customers nationwide. Our attention to detail, unmatched customer service, and dedication to helping our customers live happier, healthier lives are just a few of the many reasons we are one of the fastest growing catheter and ostomy supply companies in the nation!
Comfort Medical employees are required to conduct business to the highest ethical and professional standards; comply with applicable laws and regulations, the Advamed Code of Ethics on Interactions with Healthcare Professionals, and company policies.
Comfort Medical is committed to a policy of Equal Employment Opportunity (EEO) which means we employ and promote individuals based on their merits, regardless of race, color, religion, sex, national origin, age, disability, veteran status, pregnancy, sexual orientation, gender identity or expression, genetic information, marital status, citizenship status, status with regards to public assistance or any other protected classification.
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