Credentialing Analyst, Clinics

Elevance Health•Atlanta, FL

3d•Hybrid

About The Position

The Credentialing Analyst, Clinics is responsible for accurate and prompt credentialing for health plans and pharmacy benefit managers (PBM) for all pharmacy sites. This role requires associates to be in-office 1-2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. Alternate locations may be considered if candidates reside within a commuting distance from an office. Candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law.

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.

Nice To Haves

Knowledge of Medicaid, Medicare, managed care, and PBM providers.
Certified Provider Credentialing Specialist and college course work.

Responsibilities

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.