Remote Provider Credentialing Coordinator

Navitus Health Solutions, LLC; Town of King (WI); Remote; USD 28,000 - 33,000; Full time

Benefits offered by this job

Health insurance

Dental insurance

Vision insurance

PTO 20 days

Parental leave 4 weeks

Holidays 9

401K match 5%

Adoption assistance

Flexible Spending Account

Education assistance

Professional memberships

Referral bonus

Job summary

Navitus Health Solutions is seeking a Coordinator I, Provider Credentials to join our team and manage the credentialing workflow for pharmacy providers. You will handle receipt, processing, first-level evaluation, and reporting in collaboration with NCPDP, HMS, DEA, and state/federal databases.

The role reports to the Manager of Provider Services, ensuring adherence to Navitus policies and URAC standards, while supporting analytics, audits, and timely credentialing decisions for a compliant

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

Communication skills

Analytical skills

Multi-priority management

Independent work

Interpersonal skills

Education

High school diploma or equivalent

Advanced degree preferred

Tools

Microsoft Office

Job description

Navitus Health Solutions is seeking a Coordinator I, Provider Credentials to join our team and manage the credentialing workflow for pharmacy providers. You will handle receipt, processing, first-level evaluation, and reporting in collaboration with NCPDP, HMS, DEA, and state/federal databases.

The role reports to the Manager of Provider Services, ensuring adherence to Navitus policies and URAC standards, while supporting analytics, audits, and timely credentialing decisions for a compliant