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The Director is responsible for leading and managing the Audits, Credentialing, and Licensing team, ensuring compliance with all rules, regulations, while driving to meet the strategic goals of the organization. Overseeing all credentialing and licensing requirements in the DME space, maintaining up-to-date knowledge on industry standards and ensuring timely submissions. The Director manages relationships and contracts with payors, oversees successful external audits, and ensures staff training in regulatory changes affecting reimbursements. The role also supports the continuous development and maintenance of processes that enhance the customer experience and ensure compliance with all regulations and company standards. The Director assumes local responsibility for DME compliance, liaising with regulatory agencies, fostering a culture of compliance, and frequently communicates status and progress to the leadership team.
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- Leadership and team management - Leading, guiding, evaluating, hiring, and managing the work of direct reports in the Audits, Credentialing, and Licensing team with the goal of remaining compliant with all rules and regulations while working to accomplish the strategic and tactical goals of the organization. Regularly meeting with leadership team/direct reports to communicate direction and stay informed of the performance of the business, while holding team accountable to department goals.
- Credentialing and Licensing – Oversee and ensure compliance with all credentialing and licensing requirements in the durable medical equipment (DME), as well as other pertinent national, regional, and local requirements. This includes managing the process of obtaining, verifying, and maintaining necessary licenses, permits, and certifications for the organization. Responsible for staying up-to-date with industry regulations and standards, coordinating with relevant departments to facilitate the application and renewal processes, and ensuring timely submissions. Troubleshoots and resolving any issues related to credentialing or licensing, liaising with corporate compliance and legal, external agencies, and maintaining an organized database of all credentials and licenses.
- Insurance contracts, account management, and audits – Responsible for the relationship and contracts with all payors (commercial, Medicare, and Medicaid), work is closely coordinated between own team and other functions to maintain business integrity while maximizing access to covered lives. Ensures that external audits (examples: MAC, RAC audit & CMS matters) are successful, completed on time, and bring ongoing learnings back to operations for process improvement. Actively partakes in monitoring updates in Medicare/Medicaid/Commercial payor regulations and communicates/collaborates with Finance Manager, Supervisors, and other departments affected by such changes to ensure that staff is properly trained in regulatory changes that affect reimbursement practices.
- Processes and enterprise systems – As part of leadership team, proactively seeks opportunities in the development, implementation, and ongoing maintenance of approaches to support our customer experience and order to cash processes while driving efficiencies. This includes providing input, feedback, and approval of processes and business decisions within Comfort Medical, ensuring compliance with all applicable US laws, regulations, as well as Coloplast standards and policies.
- Compliance – Takes on the local responsibility for DME compliance matters and works closely with the corporate compliance and legal teams to drive local execution of the comprehensive compliance program of Coloplast Corp (parent company). Continuously drives a proactive approach to risk management and operates as primary liaison with regulatory agencies, ensuring timely reporting and addressing any inquiries or concerns. Works to foster a culture of compliance throughout the organization by providing regular training, updates, and feedback to all relevant staff. Take pivotal leadership in ensuring that the organization not only meets but exceeds, industry standards and best practices, incl. ensuring that all processes and SOPs are in compliance with our HIPAA privacy standards, all state and local laws, our Accrediting agency, OSHA, Medicare/Medicaid, Third-Party and private payor guidelines.
- Conducts business to the highest ethical and professional standards; complies with applicable laws and regulations, the AdvaMed Code of Ethics on Interactions with Healthcare Professionals, and company policies. Promotes adherence to all corporate policies, practices and compliance programs.
- Looks for ways to improve the department and streamline processes.
- Continuously report progress, KPIs, plans, and results to VP, the leadership team, and other stakeholders in Coloplast Corp.
- Other duties as assigned.
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- Bachelor’s degree or equivalent
- Minimum of 10 years’ experience in audit, credentialing, compliance, or similar role
- Minimum of 10 years’ experience managing a team in a fast-paced DME or healthcare environment
- Strong contract, financial, and business acumen and excellent strategic business understanding
- Knowledge of Medicare, Medicaid, commercial insurers, related regulations, billing codes, specifically of diagnostic and procedural terminology, ICD and CPT/HCPCS coding systems, licensing and compliance rules, as well as audits
- Able to effectively communicate with all levels and areas of the organization, leading multiple projects and manage deadlines; proficient in English
- Willingness and ability to travel, including overnight – up to 30%
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