Credentialing Analyst - Infusion Clinics
Jobtailor
Responsible for accurate and prompt credentialing for health plans and pharmacy benefit managers (PBM). 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. Manages PBM credentialing requests and maintenance. Medicare (PECOS) processing for all pharmacy sites. Maintains 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. 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. Core Competencies Demonstrates expertise in credentialing and re-credentialing processes, ensuring compliance with regulatory standards and fostering relationships with managed care plans and pharmacy benefit managers. Proficient in managing pharmacy license tracking and maintaining accurate credentialing files. Highest-signal resume keywords Credentialing Management Medicaid Knowledge Medicare Processing Provider Credentialing Specialist Certification Pharmacy Benefit Manager (PBM) Experience ATS Optimization Keywords Hard Skills Credentialing Re-Credentialing Policy Review License Tracking NPI Profile Updates Medicaid Applications Medicare (PECOS) Processing NCPDP Profile Maintenance Fraud, Waste and Abuse Attestation Continuing Education Units Management Soft Skills Effective Communication Troubleshooting Collaboration Confidentiality Maintenance Professionalism Certifications & Qualifications Certified Provider Credentialing Specialist Industry Keywords Managed Care Pharmacy Benefit Managers (PBM) URAC ACHC NABP Tools & Technologies Pharmacy License Tracking Tool Credentialing Files Management System #J-18808-Ljbffr Jobtailor
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