Credentialing Specialist

Summary

The Credentialing Specialist is responsible for ensuring that all pharmacy providers and facilities meet the necessary accreditation, licensure, and compliance standards. This role involves verifying credentials, maintaining up-to-date records, and ensuring adherence to organizational and regulatory policies. The ideal candidate will have exceptional organizational skills, attention to detail, strong communication abilities, and the ability to lead and manage multiple tasks in a fast-paced environment.

Essential Duties and Responsibilities

This list of duties and responsibilities is not all inclusive and may be expanded to include other duties and responsibilities as management may deem necessary from time to time.

• Collect, verify, and maintain healthcare providers' credentials, licenses, certifications, and education records.
• Ensure timely renewal of licenses and certifications to maintain compliance with organizational and regulatory requirements.
• Process initial and reappointment credentialing applications for providers in accordance with established guidelines and timelines.
• Communicate with providers to address incomplete or missing documentation.
• Monitor and update databases with accurate provider and credentialing and licensing documentation.
• Collaborate with state licensing boards, OIG/SAM, insurance companies, and accrediting bodies to confirm provider credentials.
• Stay up to date on current laws, regulations, and standards related to pharmacy credentialing.
• Prepare reports on credentialing activities and compliance audits for management as needed.
• Maintain confidentiality and security of sensitive provider information.
• Performs other duties and responsibilities as requested or required.
• Follows company policies and procedures.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

• High School Diploma or equivalent required; associate or Bachelor's degree strongly preferred
• Two (2) experience in credentialing, medical staff services, or related field in healthcare administration
• Knowledge of healthcare accreditation standards (e.g. The Joint Commission, NCQA, URAC)
• Well-organized and detailed with the ability to communicate in an appropriate and timely manner.
• Ability to manage multiple tasks and meet deadlines in a fast-paced environment.
• Certification as a Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM) is a plus but not required.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. (The phrases "occasionally," "regularly," and "frequently" correspond to the following definitions: "Occasionally" means up to 1/3 of working time, "regularly" means between 1/3 and 2/3 of working time, and "frequently" means 2/3 and more working time.)

While performing the duties of this job, the employee is frequently required to sit, talk or hear and use hands to handle, or touch objects or controls. The employee is regularly required to stand and walk. On occasion the incumbent may be required to stoop, bend or reach above the shoulders. The employee would rarely need to lift up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus.

Work Environment

The position is based in our Milwaukee, WI office 2-3 days a week with up to 2 days a week remote pending satisfactory performance. The role has limited travel (10% or less).

The above statement reflects the general details necessary to describe the principal functions of the occupations describes and shall not be construed as a detailed description of all the work that may be inherent in the occupation

EEO Statement

SPS Health LLC and all its affiliates, are equal opportunity employers committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, sexual orientation, national origin, disability, genetic information, pregnancy, or any other protected characteristic as outlined by federal, state, or local laws.
This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, training, and apprenticeship. The Company makes hiring decisions based solely on qualifications, merit, and business needs at the time.


SALARY RANGE: $52,000 - $60,000, plus bonus potential