Remote Credentialing Analyst // 5 Years Required

Job Description:

• Responsible for leading, coordinating, monitoring, and maintaining the credentialing and re-credentialing process.
• Facilitates all aspects of credentialing, including initial applications, re-credentialing applications, expirables process, as well as maintain all Medicare and Medicaid enrollments for all pharmacies, and all other providers
• Ensures interpretation and compliance with the appropriate accrediting and regulatory agencies
• Responsible for the accuracy and integrity of the credentialing database systems and related applications
• Leads, coordinates, and monitors the review and analysis of pharmacy and practitioner applications and accompanying documents, ensuring applicant eligibility.
• Conducts research and primary source verification of all components of the application.
• Identifies issues that require additional investigation and evaluation, validates any sanctions and ensures appropriate follow up.
• Prepares credentials for all payers ensuring completion.
• Responds to inquiries from all payers and also interfaces with internal and external customers on day-to-day credentialing and issues as they arise.
• Assists with managed care credentialing audits; conducts internal file audits.
• Utilizes the NCPDP and CAQH credentialing database, optimizing efficiency, and performs query, report and document generation; submits and retrieves National Practitioner Database reports in accordance with Health Care Quality Improvement Act.
• Monitors initial, re-credentialing applications for all pharmacies, infusion clinics, Allied Health Professional staff, ensuring compliance with regulatory bodies.
• Performs miscellaneous job-related duties as assigned.
• Maintains copies of current state licenses, DEA certificates, malpractice coverage and any other required credentialing documents for all providers / pharmacies.
• Sets up and maintains provider information in online credentialing databases and system.

Qualifications:

• Six years of experience in the medical field, required
• Minimum of four (4) years directly related to Managed Care credentialing
• Certification/Licensure NAMSS Certification as a Certified Professional Medical Services Manager (CPMSM)
• OR Certified Provider Credentials Specialist (CPCS)
• OR actively pursuing certification, preferred.