Provider Credentials Specialist — Remote

Navitus Health Solutions, LLC; Crystal Bay (NV); Remote; USD 28,000 - 33,000; Full time

Benefits offered by this job

Health, Dental, and Vision insurance

20 days paid time off

4 weeks paid parental leave

9 paid holidays

401K company match up to 5%

Adoption Assistance

Flexible Spending Account

Educational Assistance Plan and Pro/M–

Referral Bonus Program – up to $750

Job summary

Navitus Health Solutions, LLC is seeking a Coordinator I, Provider Credentials to join our team. The role focuses on facilitating receipt, processing, and first-level evaluation of provider credentials across state and federal databases.

Responsibilities include maintaining credential records, generating reports, and ensuring compliance with policies and URAC standards. The candidate will interact with providers and Navitus teams to support a compliant, credentialed pharmacy network.

Qualifications

• High school or equivalent, advanced degree preferred.
• Retail pharmacy experience or experience in a managed care pharmacy setting desired.
• Prior experience analyzing medical and/or pharmacy claims or credentials highly desired.
• Ideal candidate will be able to work independently, have telephonic and written communication skills, data-mine variable databases, analytical skills and can manage multiple priorities.
• Ability to professionally interact with providers at all levels (both internal and external) is required.
• Must be able to function independently, however work closely with individuals within other departments.
• Candidate must be proficient in Microsoft applications.
• Candidate must rely on knowledge of Navitus’ business concepts, practices, and policies and procedures to accomplish goals.
• Participate in, adhere to, and support compliance program objectives.
• The ability to consistently interact cooperatively and respectfully with other employees.

Responsibilities

• Daily communication with Navitus pharmacy providers, including Navitus’ strategic vendor(s), to obtain, review, and process credentials.
• Ensures that pharmacy credentials are received, documented in appropriate systems, and retained in pharmacy contract files. Audits files or systems to identify non-compliant documentation.
• Supports compliance to URAC and Navitus’ policy and procedures to ensure a quality credentialed pharmacy network. Ability to enrich P&Ps to meet new or updated statutes, laws, regulations, or guidance
• Create reports of credential activity, including positive credentials, negative credentials, issues associated with credentials, etc. Reports submitted to department VP and to Credential Committees
• Monitors and extracts information from credential databases, such as HMS, NCPDP, OIG, DEA, State Boards of Pharmacy, and others as identified
• Support Pharmacy Network personnel in administration of the Navitus pharmacy programs with providers, resolution of pharmacy contractual pricing questions or issues, communication of processing requirements to providers and general resolution of processing issues
• Supports obtaining and reporting of annual Fraud, Waste, and Abuse attestations from providers. Supports obtaining other attestations as required supporting Navitus business practices
• Updates systems to reflect data consistent with external databases, such as NCPDP, as appropriate
• Assists VP and other Network Development associates in the determination, review, and implementation of pharmacy network strategies
• Other duties as assigned

Skills

Retail pharmacy experience

Claims analysis

Independent work

Verbal and written communication

Microsoft Office

Interdepartmental collaboration

Education

High school or equivalent, advanced degree preferred

Tools

NCPDP

HMS

DEA

Job description

Navitus Health Solutions, LLC is seeking a Coordinator I, Provider Credentials to join our team. The role focuses on facilitating receipt, processing, and first-level evaluation of provider credentials across state and federal databases.

Responsibilities include maintaining credential records, generating reports, and ensuring compliance with policies and URAC standards. The candidate will interact with providers and Navitus teams to support a compliant, credentialed pharmacy network.