Credentialing Analyst, Pharmacy
Elevance Health
full-time
Posted on:
Location Type: Hybrid
Location: Lake Mary • Florida • Virginia • United States
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About the role
- 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
- 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
Requirements
- Requires a H.S. diploma or equivalent
- minimum of 3 years experience
- Strongly preferred certified Provider Credentialing Specialist
- college course work
Benefits
- merit increases
- 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
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
credentialingre-credentialingMedicaid applicationsMedicare processingNPI profile updateslicense trackingcredentialing policiesfraud preventionaccreditation supportContinuing Education Units
Soft skills
troubleshootingcollaborationcommunicationconfidentialityorganizationattention to detailproblem-solvingprofessionalismrelationship buildingtime management
Certifications
Provider Credentialing Specialist