Credentialing and Licensing Specialist

Job Description:

• Oversee initial and ongoing payer enrollment, credentialing, recredentialing, revalidation, and regulatory reporting activities
• Ensure compliance with federal, state, contractual, and payer-specific requirements
• Obtain, renew, and maintain business and operational licenses and registrations, including Board of Pharmacy, HME/DMEPOS, facility, business, and Secretary of State filings
• Manage payer information within patient management and billing systems
• Process 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 payer portals, demographic maintenance, ownership updates, licensure updates, revalidations, and enrollment records
• Manage company licenses, state DME permits, supplier registrations, business licenses, and accreditation requirements
• Maintain Medicare supplier enrollment records and PECOS-related documentation
• Prepare and submit ownership disclosures, corporate structure updates, adverse action disclosures, and other regulatory filings
• Set up and maintain EDI enrollments, electronic claims submission processes, clearinghouse relationships, payer IDs, and payer connectivity
• Process EFT and ERA applications
• Maintain contract-related reference sheets, job aids, tracking sheets, and reference guides
• Distribute internal communications regarding new payer contracts or policy changes
• Maintain reimbursement fee schedules and payer-specific pricing information
• Communicate contracted payer participation status to internal and external stakeholders
• Assist the Market Access Team with commercial contract and health plan applications or credentialing initiatives
• Maintain compliance with Medicare supplier standards, accreditation requirements, regulations, payer requirements, and company policies
• Conduct business according to applicable laws, ethical standards, and company policies
• Perform other duties as assigned

Requirements:

• High school diploma or equivalent required
• 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
• Experience with Medicare, Medicaid, commercial payers, or healthcare network operations preferred
• Knowledge of payer enrollment, credentialing, contracting, licensing, or regulatory compliance processes preferred
• Experience with payer portals, EFT/ERA enrollment, or provider/supplier data management preferred
• Familiarity with HIPAA and healthcare privacy requirements preferred
• Experience in the Durable Medical Equipment (DME) industry preferred

Benefits:

• Comprehensive medical, dental, and vision insurance plans
• Company-sponsored wellness programs
• Mental health resources
• Paid leave of absence for qualifying events
• Generous paid parental leave for birthing and non-birthing parents
• Competitive 401(k) plan with immediate company match vesting
• Financial planning services
• Corporate discount programs
• Generous paid time off
• Flexible work hours
• Flexible work arrangement options may be available
• Training programs
• Mentorship
• Tuition reimbursement
• Recognition programs, including peer recognition
• Bonuses
• Awards and special events
• Team-building activities
• Volunteer opportunities
• Company-sponsored events