Position Summary
The Credentialing Specialist is responsible for coordinating and maintaining the credentialing and re-credentialing processes for pharmacists, pharmacy technicians, and contracted providers. This position ensures compliance with regulatory and payer requirements and supports enrollment processes with pharmacy benefit managers (PBMs), health plans, and accreditation bodies (e.g., URAC, ACHC, NABP).
Primary Responsibilities
• Complete timely internal audits that ensure we are in compliance with Medicare regulation and guidelines
• Track and manage Business Associate Agreements internally.
• Support accreditation activity as directed by Director, Compliance.
• Track license expiration dates, DEA registrations, and other critical compliance documents.
• Maintain accurate records in credentialing databases and document management systems.
• Assist with documentation and audits during accreditation, reaccreditation, or payer reviews.
• Submit and track pharmacy enrolment applications with insurers, networks, and state boards.
• Collect, review, and verify licensure, certifications, education, and work history for pharmacists and pharmacy technicians.
• Ensure timely credentialing and re-credentialing of providers and facilities according to payer and regulatory timelines.
• Assist the Director, Compliance with enrollment processes with commercial and government PBMs (e.g., Express Scripts, OptumRx, CVS Caremark, Medicare Part D).
• Create official minutes from Quarterly Quality and Compliance Meetings
• Manage new hires and annual compliance trainings throughout the entire process.
• Other tasks as assigned
K ey Skills
• Strong understanding of specialty pharmacy workflows and credentialing standards
• Exceptional organizational and time management skills
• High attention to detail and data accuracy
• Accurately interprets written instructions and documents.
• Strong analytical and critical thinking skills.
• Excellent verbal and written communication skills.
• Detail-oriented, organized, and capable of handling confidential data appropriately. Knowledge of pharmacy operations and support systems
• Proficiency in Microsoft Office and credentialing management software
• Knowledge of pharmacy-related compliance requirements (DEA, HIPAA, CMS Part D, 340B).
• Familiarity with PBM and payer enrollment processes
Education/Experience Requirements
• Associate Degree or equivalent work experience.
• 2+ years in pharmacy credentialing, pharmacy operations, or healthcare credentialing.
• Experience working with pharmacy claims data, EMRs, or pharmacy management systems (e.g., PioneerRx, QS/1, Epic)
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