Credentialing Analyst, Infusion Clinics/Nursing
About The Position
The Credentialing Analyst, Infusion Clinics/Nursing 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. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office. Please note that per our policy on hybrid/virtual work, 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.
Benefits
- comprehensive benefits package
- incentive and recognition programs
- equity stock purchase
- 401k contribution
- paid holidays
- Paid Time Off
- incentive bonus programs
- medical, dental, vision, short and long term disability benefits
- 401(k) +match
- stock purchase plan
- life insurance
- wellness programs
- financial education resources
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
