Medical Credentialing Specialist

  • Full-time

Company Description

Here at CiNQ Recruitment, we believe in finding the right fit, for you and our clients. Whether you seek long-term employment solutions for your business or your next career move, we understand the importance of individual and business needs. With over 30 years of successful staffing and recruiting experience, we excel at providing passive candidates with the right skills and cultural fit for specialized positions. Here is the opportunity to work with an exciting pharmaceutical company.

Job Description

Job Type: Full time with Benefits

Shift: Monday- Friday 8am-5pm

Salary: 40-44K

*Specialty Pharmacy is seeking a Credentialing Specialist to join their team!*

Hiring manager's Must Have:

  • Experience with initial pharmacy permit application and renewals
  • Medicaid revalidations and new applications
  • Medicare revalidation
  • Payor knowledge and background
  • Re-credentialing of payor contracts
  • Specialty Pharmacy background- PREFFERED

Position Summary:

Responsible for accurate and prompt credentialing for health plans and pharmacy benefit managers (PBM) for all pharmacy sites. Acts as a troubleshooter in resolving payor departmental issues related to credentialing; develop performance improvement plans as needed. Communicate effectively with internal teams and develop relationships with health plans, PBM’s, and external customers.

Essential Functions:

  • 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 re-credentialing
  • 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
  • Maintain NCPDP profile for all pharmacy sites
  • Certificate of Insurance updates and dissemination to plans
  • NPI updates (NPPES)
  • URAC, ACHC support during accreditation implementation or reviews
  • Fraud, Waste and Abuse annual attestations
  • Manage pharmacy Continuing Education Units for RFP’s
  • Pull and maintain credentialing documents for RFP’s
  • Knowledge of Medicaid, Medicare, managed care and PBM provider manuals.
  • Additional responsibilities as assigned by the Senior Director of Contract Management
  • Submit Pharmacy Permits and Renewals
  • Submit Pharmacist in Charge changes and renewals

Education/Experience Requirements:

  • Associate’s degree in healthcare related field preferred
  • 3+ years of experience of Medicare, Medicaid and Managed care credentialing

Additional Information

All your information will be kept confidential according to EEO guidelines.