Manager Credentialing and Licensing

The Manager Credentialing and Licensing will be responsible for the ongoing progression and maintenance of the company's corporate compliance and accreditation program, HME licensing and payer portal access. In addition, this role will play a key function in our training and education initiatives, policy and procedure review/development and monitoring, auditing activities to support key compliance controls and the business' functional departments. The Manager will also partner with the VP, Compliance and Sr. Compliance Manager to manage activities and departmental initiatives to ensure project/department milestones and goals are met.

• Primary responsibility for management and oversight of:
  • Medicare and Medicaid Fee for service supplier enrollment and manage individual employee access
    • Maintain PECOS and Medicare regions on-line registrations
    • Ensure all necessary remote TCMD locations maintain effective enrollment
    • Submit applications to Medicare Regions for CSI and VPIQ user access for new employees
    • Annual maintenance of all users (CSI and VPIQ) for all Medicare regions
    • Ensure Company information is accurate and updated, as needed
    • Complete biannual (January/July) review of each Medicare allowable by state and ensure appropriate database updates are complete (currently FileMaker)
  • Payer portal access: serve as the Provider Administrator for payer portals, ensuring timely onboarding and offboarding for access to appropriate employees, ensure implementation of appropriate access controls
  • Management and administration of state HME licensing as required to conduct business in each state/municipality
• Manage all aspects credentialing, including
  • Ensuring compliance with relevant standards,
  • Maintain oversight of ACHC standards, identifying updates, changes, edits and managing any resulting changes in company policy, processes
  • Lead accreditation renewal activities across the organization
  • Ensure training and collateral materials related to credentialing are effective and up to date
• Manage the Medicare, Medicaid and Accreditiaton requirements applicable to satellite offices including
  • Ensuring effective training and education with regard to all applicable requirements including addressing and responding to site visits by regulatory and accrediting entities
  • Appropriate documentation and collateral materials are maintained
  • Updated resources and contacts are available
  • Coordinate with applicable internal teams as needed to ensure effective management and oversight of these location to meet the regulatory and accreditation requirements
• Serve as the Performance Improvement Coordinator, Compliance to facilitate effective management and operation of the company's performance and quality management activities
• Prepare operational communications and determine optimal methods for delivery to affected departments
• Assist with investigation of compliance issues and questions including suspected nonconformities to the company's compliance program requirements
• Assist with contract management to ensure compliance to company requirements and renewal process as appropriate (including tracking, follow up, communications)
• Assist with revision to company policies and procedures as required to ensure conformance to accreditation standards and regulatory requirements
• Support annual sunshine act reporting (Federal and state requirements)
• Collaborate with other functional departments such as Reimbursement, Commercial Operations, Marketing, Sales, Regulatory and Quality to ensure activities are consistent with regulatory and legal requirements
• Assist with external and internal compliance and regulatory audits, reviews, attestations and assessments
• Assist with ensuring the compliance program requirements are fulfilled, including supporting the elements of program reviews
• Collaborate with internal and external stakeholders on compliance issues and solutions
• Develop relevant key performance indicators, dashboards, and analytics that drive reporting, risk management and remediation
• Foster development of a supportive, inclusive and positive compliance culture
• Keep abreast of regulatory changes and developments in the medical device environment

Education & Experience

Required:

• 5+ years of experience in a legal, compliance or operational process role within a healthcare/medical device environment

Preferred:

• Associate or bachelor's degree
• Certification as CHC, CHPC or other accredited regulatory compliance certification program or willingness to become certified

Knowledge & Skills

• Extensive knowledge of operational processes to assess, recommend and facilitate process and functional improvements.
• Understanding of compliance concepts in the healthcare industry (especially fraud and abuse, confidentiality/protected health information, electronic security, anti-kickback, physician/clinician "sunshine" reporting and general regulatory compliance strategies)
• Familiarity and understanding of:
  • False Claims Act;
  • Anti-Kickback statute
  • HIPAA
  • Sunshine Act/Open Payments Reporting (and separate state statutes)
  • AdvaMed Code of Ethics
  • Stark Law
  • DOJ: Regulatory Compliance Guidelines
• Understanding of state licensure requirements for clinical/DME facilities
• Knowledge of Medicaid/Medicare ongoing enrollment requirements and recredentialing
• Knowledge of third-party payers, including government funded programs, initial enrollment, ongoing maintenance, and data management necessary to support continued and uninterrupted provider status
• Knowledge of the laws, standards and regulations that apply to the Company's licensing and credentialing standards necessary to support business operations (HME, other local licensing and credentialing standards and requirements)
• Ability to operate in a fast-paced environment with flexibility to prioritize, balance and respond to competing needs within the organization
• Ability to multitask while maintaining strong organizational, analytical and research-oriented skills
• Excellent oral and written communication skills
• Highly effective communicator with the ability to partner cross-functionally to identify and resolve issues