Credentialing and Contracting Specialist - 21326

somewhere; United States; Remote; USD 65,000 - 90,000; Full time

Job summary

Unknown is a rapidly growing U.S.-based DME supplier specializing in diabetes technology such as CGMs and insulin pumps. The newly created Credentialing and Contracting Specialist role owns payer enrollment, contracting, and AR follow-up end-to-end, building tracking systems and processes to ensure timely contracts and paid claims.

The role requires 2+ years of credentialing or AR experience with U.S. payers and strong communication skills for remote collaboration with payer representatives.

Qualifications

• Two or more years of U.S. payer credentialing or AR experience.
• Knowledge of Medicare, Medicaid, and commercial payer enrollment requirements.
• Experience resolving denied/underpaid claims through appeals.
• Ability to interpret contracts, fee schedules, EOBs, and remittance advices.
• Excellent English, both spoken and written.
• Strong organizational skills to manage many open applications and renewals.
• Ability to work independently in a remote environment (ET hours).

Responsibilities

• Manage payer enrollment and contracts, tracking status and requirements.
• Complete credentialing, re-credentialing, revalidation, and participation applications.
• Follow up with payer reps by phone/email/portal until determinations.
• Review contracts, fee schedules, and amendments; escalate when needed.
• Maintain CAQH, PECOS, NPPES, and payer portal profiles.
• Monitor licensure, accreditation, surety bond, liability insurance, and enrollments.
• Respond to payer documentation requests and audits.
• Conduct denial resolution and appeals with clinical documentation.
• Establish tracking systems and report denial trends.
• Document payer contacts and status updates.
• Maintain up-to-date payer participation status.

Skills

Provider credentialing

Payer enrollment

Accounts receivable follow-up

Medicare/Medicaid enrollment

Contract interpretation

English communication

Remote work coordination

Tools

CAQH

Availity

Payer portals

HCPCS coding knowledge

Job description

Credentialing and Contracting Specialist

Location: Remote Hours: Monday–Friday, 9:00 a.m.–5:00 p.m. Eastern Time Employment Type: Full-time ICReports to: Operations Manager

About the Company

We are a rapidly growing U.S.-based durable medical equipment (DME) supplier specializing in diabetes technology, including continuous glucose monitors and insulin pumps from leading manufacturers. Headquartered in the New York metro area, we serve patients nationwide and are contracted with Medicare, Medicaid, and most major commercial payers.

We manage the entire coverage process on the patient's behalf, from enrollment and benefits verification through documentation, fulfillment, and ongoing support. As we expand our payer footprint and patient base, we are building out the internal functions that keep us participating with payers and ensure we are paid accurately for the care we deliver.

About the Role

This is a newly created position, and it exists to bring two revenue-critical functions under clear, dedicated ownership.

The first is payer enrollment and contracting: keeping us in good standing with every government and commercial payer we work with, and getting us contracted with new ones so we can reach more patients. The second is accounts receivable follow-up: making sure denied, underpaid, and partially paid claims are pursued and resolved through final payment rather than written off by default.

Both functions have been handled reactively as we've grown. This role owns them end to end and builds the tracking systems and processes to run them well. It is a strong fit for someone who wants to own a function, not just work a queue, and who takes satisfaction in turning a denied claim into a paid one and a stalled application into an active contract.

Key Responsibilities

Payer Enrollment and Contracting

• Manage all payer applications and contracts in progress, tracking current status, outstanding requirements, and responsible party for each
• Complete credentialing, re-credentialing, revalidation, and Request for Participation applications for government and commercial payers
• Conduct persistent follow-up with payer reps, provider relations, and network management by phone, email, and portal until each application reaches a determination
• Review executed contracts, fee schedules, and amendments, and elevate rates, terms, or carve-outs that require management review

Credentialing File and Compliance Maintenance

• Maintain accurate organizational profiles in CAQH, PECOS, NPPES, and payer portals
• Keep current demographics with all payers, including legal and DBA name, service and billing addresses, NPI, TIN, ownership, and designated contacts
• Monitor expiration and renewal dates for licensure, accreditation, surety bond, liability insurance, and payer enrollments, and initiate renewals ahead of any lapse
• Maintain the supplier documentation file, including state licensure, DMEPOS accreditation, Form W-9, ownership disclosures, and Medicare and Medicaid enrollment records
• Respond to payer documentation requests, audits, and site visit requirements

Claims Follow-Up and Denial Resolution

• Work aged accounts receivable by balance and age, prioritizing claims approaching timely filing deadlines
• Contact payers by phone and portal to determine claim status and drive substantive resolution, not just acknowledgment of receipt
• Research and resolve denied, underpaid, and partially paid claims: identify root cause and correct, resubmit, or appeal
• Prepare and submit appeals supported by clinical documentation and citation to the payer's applicable coverage policy
• Reconcile remittance advices and EOBs, and identify and dispute recoupments, takebacks, and payments below contracted rates
• Manage each claim to final resolution: payment in full, documented contractual adjustment, or approved write-off

Reporting and Process Building

• Establish and maintain the tracking systems that support both credentialing and AR functions
• Track and report denial trends and root causes so recurring issues can be corrected at the source
• Document all payer contact, including representative name, reference number, and next action
• Maintain a clear, current view of participating status by payer that the organization can rely on

Required Qualifications

• Two or more years of experience in provider credentialing, payer enrollment, or medical accounts receivable follow-up with U.S. payers
• Working knowledge of Medicare, Medicaid, and commercial payer enrollment and reimbursement requirements
• Demonstrated experience resolving denied and underpaid claims through appeal
• Ability to interpret contracts, fee schedules, EOBs, and remittance advices
• Professional spoken and written English strong enough for daily phone contact with U.S. payer representatives
• Strong organizational skills and the ability to manage a high volume of applications, renewal dates, and open claims at once
• Ability to work independently in a remote environment during Eastern Time hours, with reliable internet and a workspace suitable for phone calls

Preferred Qualifications

• Experience with a DME supplier, particularly continuous glucose monitors and insulin pumps
• Familiarity with Medicare DMEPOS enrollment, including Form CMS-855S and PECOS, and with New York Medicaid
• Experience with CAQH, Availity, and major commercial payer provider portals
• Working knowledge of HCPCS coding, modifiers, and prior authorization requirements
• Certified Provider Credentialing Specialist (CPCS) or equivalent

Ideal Candidate Profile

You are highly organized and self-directed, comfortable owning a function without being managed through it. You are persistent on the phone: you know the difference between a payer rep confirming receipt and a payer rep actually resolving the issue, and you don't hang up until you have the second one. You read a denial or an underpayment as a problem to be solved, not a line to be written off, and you can build the tracking and process to keep dozens of applications and open claims moving at once. You communicate clearly and professionally with U.S. payers by phone, and you document as you go.

Why Join This Role

This is a build-it opportunity inside a growing company. You will own two functions that directly protect revenue and patient access, set up the systems that run them, and see the impact of your work in cleaner AR and uninterrupted payer participation.