Credentialing Analyst, Clinics

Role Overview

• Acts as a troubleshooter in resolving payor departmental issues related to credentialing
• Manages and maintains pharmacy license tracking tool to advise pharmacy sites and pharmacists of license renewals
• Maintains confidentiality of all pertinent pharmacy and provider information
• Administers credentialing and re-credentialing to ensure compliance with regulatory, accreditation and various managed care plan policies and protocols, standards, and requirements
• Develops and fosters collaborative relationships with managed care plans, state agencies and PBM’s to facilitate timely credentialing and re-credentialing of applications
• Tracks credentialing and re-credentialing to ensure compliance with time sensitive materials
• Maintains all pharmacy site credentialing and re-credentialing files, electronic and paper
• Effectively communicates with admission, billing, and clinical teams in a professional manner
• Reviews all credentialing policies and procedures for accuracy and completeness
• Suggests revisions of policies and procedures when necessary
• Completes new Medicaid applications and renewals or revalidations
• Medicaid portal maintenance and updates
• Medicaid administrator user access for billing
• Pull Medicaid remits for billing team upon request if portal access is limited
• Manage PBM credentialing requests and maintenance
• Medicare (PECOS) processing for all pharmacy sites
• Maintain NCPDP profile for all pharmacy sites
• Certificate of Insurance requests and dissemination to plans or CMS
• NPI profile updates (NPPES)
• URAC, ACHC, NABP support during accreditation renewals
• Fraud, Waste and Abuse annual attestation submission to health plans
• Manage pharmacy Continuing Education Units for RFP’s
• Pull and maintain credentialing documents for payor applications
• Submit new pharmacy license applications and renewals for all pharmacy sites
• Submit Pharmacist in Charge state license changes and renewals
• Additional responsibilities as assigned

Requirements

• Requires a H.S. diploma or equivalent and a minimum of 3 years experience
• Knowledge of Medicaid, Medicare, managed care, and PBM providers
• Certified Provider Credentialing Specialist and college course work

Benefits

• comprehensive benefits package
• incentive and recognition programs
• equity stock purchase
• 401k contribution