Network Credentialing Specialist

Duties:
The primary purpose of the job is to:
• Tracking and monitoring pharmacy credentials to ensure compliance with plan standards, accreditation agencies and state and federal regulatory guidelines. 
• Issuing notification to pharmacies when there are lapses in compliance information. 
• Maintaining up to date credentialing on Pharmacies to ensure contract compliance.
• Executing updated Pharmacy contract drug rate information. 
• Ensuring contracted rates are properly recorded and communicated within the Argus and the PerformRx data bases. 
• Ensuring integrity is maintained within various data, i.e. Argus SNA and the PerformRx Access database. 
• Reviewing, mailing and communicating with Pharmacy staff on new contracts and other issues as they arise.
• Validating Argus SNA system and IPNS to ensure contracted rates are reelected within the claims processing system. 
• Updating information against the NCPDP file for address, new and closed pharmacies, and other key metric information as needed.
• Reporting key Pharmacy metric information regarding credentials. 
• Work with contracting to suspend/ remove from network any pharmacies not meeting credential requirements.
• Manage and monitor each client network structure with the Pharmacy Network database, SNA and IPNS.
• Responding to Pharmacy complaints by researching and communicating issues to internal groups or escalating according to department and company policy. 
• Providing explanations on claim status, policy changes and payment decisions.
• Coordinating activities impacting inter/intra departments to ensure smooth coordination of members related inquiries.
• Maintains proactive and effective communication with all members of the departmental team and communicates any concerns appropriate staff immediately. Continuously evaluates administrative operational procedures and recommends changes as appropriate
• Performs other related duties and projects as assigned.  Including communications to Pharmacies and other related entities as needed.  Participating in executed contract activities as needed.
• Attends required training as necessary.
• Supports and carries out the Mercy Mission & Values. 
• Adheres to PerformRx/AMFC policies and procedures. 
• Maintains a current knowledge base of program services, policy and procedures. 
• Regularly reviews and reacts to policy updates and departmental procedures.
• Creates and supports an environment which fosters teamwork, cooperation, respect and diversity.  Establishes and maintains positive communication and professional demeanor with PerformRx employees and clients at all times. 
• Demonstrates and supports commitment to corporate goals and mission.

Skills:
• Job related experience.
• High School Diploma or GED Required
• Associate's Degree Preferred Current Pharmacy Technician (PTCB) Certification
• Healthcare knowledge
• Previous customer service experience in a managed care environment.

Education:
• High School Diploma or GED Required
• Associate's Degree Preferred

Skills and Experience:
Required Skills: 
• DATABASE
• PHARMACY
• SNA
• TRAINING
• ARGUS

Additional Skills:
• CLAIMS
• CLAIMS PROCESSING
• CLAIMS PROCESSING SYSTEM
• CONTRACTS
• CUSTOMER SERVICE
• CUSTOMER SERVICE ORIENTED
• DATABASES
• MANAGED CARE
• PTCB
• RETAIL SALES
• SELF MOTIVATED

Languages:
• English: Read, Write, Speak

Minimum Degree Required:
• Completed High School (Diploma or GED)

Reach Out to a Recruiter


  • : jaid@vtechsolution.us