Manager, Payer Credentialing

Responsible for supervising, planning and directing the Credentialing and Payer Relations processes.  Will oversee all credentialing and payer relations activities, including business licensing, regulatory and accreditation activities, implementation and management of all insurance contracts (both government funded and third-party) and price table maintenance.  Will work with leadership to ensure that team priorities are aligned with Comfort Medical Leadership Team (CMLT) objectives. 

Major Areas of Accountability

Leadership and team managment-

• Accomplish results by communicating expectations, planning and properly coaching and mentoring team members
• Collaborate with HR to recruit required staff positions as well as train and orient the corresponding hires to their job function
• Will own the company enrollment process with both governement funded and third-party payers and will work to minimize any interuptions for all enrollments
• Will own the contract implementation and price table management process and will work to ensure such processes reduce unanticipated revenue adjustments
• Provide team leadership and guidance to improve efficiency & effectiveness of team processes
• Provide project leadership that ensures adherence to regulatory guidelines as change occurs
• Assist in preparing for recurring meetings with key stakeholders to ensure all affected departments are informed of the progress/challenges being made and where improvements should be made

Job Duties-

• Manage provider credentialing and re-credentialing applications for government-funded and commercial insurance payers; monitor applications and follows up as needed
• Conduct periodic reviews to ensure proper adherence to state licensing and state registration requirements
• Maintain and ensure the good standing of the company’s Surety Bonds and state registration and its annual Secretary of State (SOS) reports and/or filings
• Manage the setup of electronic claims, ERA and EFT with insurance companies
• Manage and ensure the correct standing of contracted and non-contracted fee schedules in the company’s Brightree database
• Work with leadership to maintain an act of accreditation readiness and oversee any accreditation processes as it relates to the organization
• Maintain and assist with the implementation of the policies and procedures, including Standard Operating Procedures required by Comfort Medical as a covered entity
• Oversee the analysis, maintenance, and communication of records required by law or local governing bodies, or other departments in the organization
• Assist with the implementation of new technologies, tools and system applications, as may be applicable, that have the ability to increase production and streamline processes or procedures
• Observe legal and ethical guidelines for safeguarding patient and company confidentiality (HIPAA) and ensure that staff is in compliance with HIPAA and PHI regulations
• Meet individual, departmental, and company goals
• Other duties as assigned

Basic Qualifications

• Bachelor’s degree or equivalent
• Minimum of 5 years’ experience in credentialing, licensing, or similar role
• Excellent written and verbal communication skills
• Ability to work successfully as an individual and team contributor
• Strong contract, financial, and business acumen and excellent strategic business understanding
• Ability to clearly articulate in both oral and written format
• 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.

Preffered Qualifications

• 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
• Working knowledge of Brightree or other similar DME business management software
• Able to effectively communicate with all levels and areas of the organization, leading multiple projects and manage deadlines; proficient in the English language
• Willingness and ability to travel, including overnight – up to 20%