Coordinator, Provider Credentials

Overview

Navitus Health Solutions is seeking a Coordinator I, Provider Credentials to join our team!

The Coordinator I, Provider Credentials is responsible for facilitating the receipt, processing, first level evaluation, and creation of Internal and external reports of provider credentials. The Coordinator I, Provider Credentials will work extensively with NCPDP, HMS, DEA, States’ provider databases, and Federal databases. The individual(s) in this position will report to the Manager of Provider Services and support Pharmacy Relations Contract Analyst(s) to ensure that all pharmacy providers are appropriately credentialed according to federal and state regulations and statutes. The Coordinator I, Provider Credentials is also accountable for ensuring the pharmacy credentialing process meets Navitus’ policies, complies with URAC standards, and ensures that Navitus does not allow non-qualified pharmacies to participate and non-qualified prescribers to process claims. The role of the Coordinator I, Provider Credentials requires knowledge of pharmacy processing practices, pharmacy laws and regulations, and verbal and written communication skills.

Is this you? Find out more below!

Responsibilities

How do I make an impact on my team?

• Daily communication with Navitus pharmacy providers, including Navitus’ strategic vendor(s), to obtain, review, and process credentials
• Ensures that pharmacy credentials are received, documented in appropriate systems, and retained in pharmacy contract files. Audits files or systems to identify non-compliant documentation
• Supports compliance to URAC and Navitus’ policy and procedures to ensure a quality credentialed pharmacy network. Ability to enrich P&Ps to meet new or updated statutes, laws, regulations, or guidance
• Create reports of credential activity, including positive credentials, negative credentials, issues associated with credentials, etc. Reports submitted to department VP and to Credential Committees
• Monitors and extracts information from credential databases, such as HMS, NCPDP, OIG, DEA, State Boards of Pharmacy, and others as identified
• Support Pharmacy Network personnel in administration of the Navitus pharmacy programs with providers, resolution of pharmacy contractual pricing questions or issues, communication of processing requirements to providers and general resolution of processing issues
• Supports obtaining and reporting of annual Fraud, Waste, and Abuse attestations from providers. Supports obtaining other attestations as required supporting Navitus business practices
• Updates systems to reflect data consistent with external databases, such as NCPDP, as appropriate
• Assists VP and other Network Development associates in the determination, review, and implementation of pharmacy network strategies
• Other duties as assigned

Qualifications

What our team expects from you?

• High school or equivalent, advanced degree preferred
• Retail pharmacy experience or experience in a managed care pharmacy setting desired
• Prior experience analyzing medical and/or pharmacy claims or credentials highly desired
• Ideal candidate will be able to work independently, have telephonic and written communication skills, data-mine variable databases, analytical skills and can manage multiple priorities
• Ability to professionally interact with providers at all levels (both internal and external) is required
• Must be able to function independently, however work closely with individuals within other departments
• Candidate must be proficient in Microsoft applications
• Candidate must rely on knowledge of Navitus’ business concepts, practices, and policies and procedures to accomplish goals
• Participate in, adhere to, and support compliance program objectives
• The ability to consistently interact cooperatively and respectfully with other employees

• Top of the industry benefits for Health, Dental, and Vision insurance
• 20 days paid time off
• 4 weeks paid parental leave
• 9 paid holidays
• 401K company match of up to 5% - No vesting requirement
• Adoption Assistance Program
• Flexible Spending Account
• Educational Assistance Plan and Professional Membership assistance
• Referral Bonus Program – up to $750!

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Navitus Health Solutions is an Equal Opportunity Employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, creed, sex, pregnancy, sexual orientation, gender identity or expression, national origin, age, disability, genetic information, veteran status, or any other characteristic protected by law.

Equal employment opportunity, including veterans and individuals with disabilities.