Remote Provider Credentials Specialist

Navitus Health Solutions, LLC; Michigan; Remote; USD 28,000 - 33,000; Full time

Benefits offered by this job

Health insurance

Dental insurance

Vision insurance

Paid time off (20 days)

Parental leave (4 weeks)

9 holidays

401K match up to 5%

Adoption assistance

Flexible Spending Account

Education & professional membership

Job summary

Navitus Health Solutions is seeking a Coordinator I, Provider Credentials to join our team. You will facilitate receipt, processing, first-level evaluation, and reporting of provider credentials, collaborating with NCPDP, HMS, DEA, and state/federal databases.

You will report to the Manager of Provider Services and support Pharmacy Relations Contract Analysts to ensure credentialing compliance with Navitus policies and URAC standards, enabling qualified pharmacies and providers to participate.

Qualifications

• High school diploma or equivalent; advanced degree preferred.
• Retail pharmacy experience or managed care setting desirable.
• Prior experience analyzing medical and/or pharmacy claims or credentials highly desired.
• Ability to work independently with telephonic and written communication, data-mine databases, and manage multiple priorities.
• Professional interaction with providers at all levels is required.
• Proficiency in Microsoft applications is required.

Responsibilities

• Daily communication with Navitus pharmacy providers and vendor(s) to obtain, review, and process credentials.
• Ensures credentials are received, documented in systems, and retained in files; audits for non-compliant documentation.
• Supports URAC compliance and Navitus policies to maintain a qualified pharmacy network; updates policies as statutes/guidance change.
• Create reports of credential activity including positive/negative credentials and issues; reports to department VP and Credential Committees.
• Monitor and extract information from credential databases (e.g., HMS, NCPDP, OIG, DEA, State Boards).
• Assist in administration of Navitus pharmacy programs and resolve pricing questions or processing issues with providers.
• Assist in obtaining Attestations for Fraud, Waste, and Abuse from providers and other required attestations.
• Update systems to reflect data from external databases as appropriate.
• Support strategy development for pharmacy networks with VP and Network Development team.
• Perform other duties as assigned.

Skills

Communication skills

Data mining

Analytical skills

multitasking

Education

High school or equivalent

Advanced degree preferred

Tools

Microsoft Office

Job description

Navitus Health Solutions is seeking a Coordinator I, Provider Credentials to join our team. You will facilitate receipt, processing, first-level evaluation, and reporting of provider credentials, collaborating with NCPDP, HMS, DEA, and state/federal databases.

You will report to the Manager of Provider Services and support Pharmacy Relations Contract Analysts to ensure credentialing compliance with Navitus policies and URAC standards, enabling qualified pharmacies and providers to participate.