Credentialing Analyst, Infusion Clinics – Nursing

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 minimum of 3 years experience; or any combination of education and experience, which would provide an equivalent background.
• 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