Credentialing and Licensing Specialist

This is a fully remote position, open to applicants in Florida.

📋 Description

• Supervise the initial and ongoing processes for payer enrollment, credentialing, recredentialing, revalidation, and regulatory reporting.

• Ensure adherence to federal, state, contractual, and payer-specific regulations.

• Obtain, renew, and maintain various business and operational licenses and registrations, including those from the Board of Pharmacy, HME/DMEPOS, facility, business, and Secretary of State filings.

• Oversee payer information within patient management and billing systems.

• Manage the application processes for payer enrollment, revalidation, credentialing, and re-credentialing for Medicare, Medicaid, managed care organizations, commercial health plans, and other contracted payers.

• Track application statuses and follow up to ensure timely participation and reimbursement.

• Administer payer accounts, portals, demographics, ownership updates, license updates, revalidations, and enrollment records.

• Oversee company licenses, state DME permits, supplier registrations, business licenses, and accreditation requirements.

• Maintain Medicare supplier enrollment records and documentation related to PECOS.

• Prepare and submit ownership disclosures, corporate updates, adverse action disclosures, and regulatory filings.

• Establish and maintain EDI enrollments, electronic claims submissions, clearinghouse relationships, payer IDs, and payer connectivity.

• Process EFT and ERA applications.

• Keep contract reference materials updated and distribute internal communications regarding payer contracts and policy changes.

• Maintain reimbursement fee schedules and payer-specific pricing information; process updates to reimbursement methodologies.

• Communicate contracted payer participation statuses to both internal and external stakeholders.

• Support the Market Access Team with commercial contract and health plan applications and credentialing initiatives.

• Ensure compliance with Medicare supplier standards, accreditation requirements, regulations, payer obligations, and company policies.

• Carry out additional duties as assigned.

⛳️ Requirements

• A high school diploma or equivalent is required; an Associate degree is preferred.

• 3-5 years of experience in healthcare administration, payer enrollment, credentialing, licensing, provider relations, or related support functions.

• Strong organizational abilities with the capacity to manage multiple priorities and meet deadlines.

• Proficient in Microsoft Office Suite and other business-related software applications.

• High attention to detail and accuracy in data entry.

• Capability to interpret instructions, policies, and payer requirements, completing tasks independently.

• Excellent verbal and written communication skills.

• Ability to adapt to shifting priorities and work efficiently in a fast-paced environment.

• Strong skills in time management, problem-solving, and decision-making.

• Ability to work autonomously as well as collaboratively in a team environment.

• Experience with Medicare, Medicaid, commercial payers, or healthcare network operations is preferred.

• Knowledge of processes related to payer enrollment, credentialing, contracting, licensing, or regulatory compliance is preferred.

• Familiarity with payer portals, EFT/ERA enrollment, or provider/supplier data management is preferred.

• Understanding of HIPAA and healthcare privacy requirements is preferred.

• Experience in the Durable Medical Equipment (DME) industry is preferred.

🏝️ Benefits

• Competitive salary and comprehensive benefits package.

• Opportunities for professional development and career advancement.

• Supportive work environment with a focus on teamwork and collaboration.

• Flexible working hours and work-life balance initiatives.