Pharmacy Credentialing Specialist

The range of pay is between $40K-$52K based on experience. 
 

The Credentialing Specialist is responsible for maintaining an active status for all providers by successfully completing initial and subsequent credentialing packages as required by state, commercial payers, Medicare and Medicaid. Credentialing Specialist provides integral support to healthcare operations by enabling timely completion of all credentialing and re-credentialing requests.

Primary Responsibilities:

• Reviews and screens initial and reappointment credentialing applications for completeness, accuracy, and compliance with federal, state, local and company guidelines, policies, and standards
• Collects highly confidential and sensitive credentials, conducts primary source verification, and validates documents to ensure accuracy of all credentialing elements; assesses completeness of information and qualifications relative to credentialing standards
• Completes credentialing applications to add providers to commercial payers, Medicare, and Medicaid
• Completes re-credentialing applications for commercial payers
• Collaborates with the billing staff to identify and resolve any denials or authorization issues related to provider credentialing
• Identifies, analyzes and resolves extraordinary information, discrepancies, time gaps and other idiosyncrasies that could adversely impact ability to credential and enroll practitioners
• Inform management of any issues in accordance with credentialing policies and procedures, federal, state, local and government/insurance agency regulations
• Monitors files to ensure completeness and accuracy; reviews all file documentation for compliance with quality standards, accreditation requirements, and all other relevant policies
• Prepares and provides information to internal and external customers as appropriate
• Enters, updates, and maintains data accurately from provider applications into credentialing database
• Prepares, issues, electronically tracks and follows-up on appropriate verifications for efficient, high-volume processing of individual applications in accordance with applicable credentialing standards, established procedural guidelines, and strict timelines
• Participates in the development and implementation of process improvements for the system-wide credentialing process
• Prepares reports and scoring required by regulatory and accrediting agencies, policies, and standards
• Communicates with providers, medical staff leadership and administration, as needed to provide timely responses upon request on credentialing and privileging issues as they arise
• Assist in various projects and other duties assigned by manager.

Qualifications:  

• Bachelor’s Degree or equivalent work experience required
• Paralegal certification preferred.
• Working knowledge of the healthcare industry, pharmacy and PBM business environment a plus. 
• Excellent working knowledge of NCPDP registration and requirements
• Excellent working knowledge of Medicare and Medicaid requirement
• Excellent verbal and written communication skills.
• Excellent critical thinking and deductive reasoning skills.
• Strong computer skills and proficient in the Microsoft Software Products.
• Ability to work collaboratively with management, internal team members, and external personnel within various existing/potential clients and vendors.
• Able to acquire, handle, store, retrieve, and understand various information rapidly and efficiently.
• Ability to deliver projects according to plan and on time.
• Ability to work independently with minimal supervision.
• Ability to manage and direct multiple projects concurrently.

Benefits: 

• Paid Parental Leave
• 401(K) Match and Vesting 
• Paid time off
• Benefits 
• Paid Holidays
• Casual Dress
• Training and Development for Career Growth