at Navitus Health Services in Montpelier, Vermont, United States
Job Description
Overview
Navitus Health Solutions is seeking a Coordinator I, Provider Credentials to join our team!
The Coordinator I, Provider Credentials is responsible for facilitating the receipt, processing, first level evaluation, and creation of Internal and external reports of provider credentials. The Coordinator I, Provider Credentials will work extensively with NCPDP, HMS, DEA, States’ provider databases, and Federal databases. The individual(s) in this position will report to the Manager of Provider Services and support Pharmacy Relations Contract Analyst(s) to ensure that all pharmacy providers are appropriately credentialed according to federal and state regulations and statutes. The Coordinator I, Provider Credentials is also accountable for ensuring the pharmacy credentialing process meets Navitus’ policies, complies with URAC standards, and ensures that Navitus does not allow non-qualified pharmacies to participate and non-qualified prescribers to process claims. The role of the Coordinator I, Provider Credentials requires knowledge of pharmacy processing practices, pharmacy laws and regulations, and verbal and written communication skills.
Is this you? Find out more below!
Responsibilities
How do I make an impact on my team?
- 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
Qualifications
What our team expects from you?
- 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
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Equal employment opportunity, including veterans and individuals with disabilities.PI288057794
