Responsible for leading, coordinating, monitoring, and maintaining the credentialing and re-credentialing process. Facilitates all aspects of credentialing, including initial applications, re-credentialing applications, expirables process, as well as maintain all Medicare and Medicaid enrollments for all pharmacies, and all other providers outlined in the Amerita Bylaws, policies, or related contracts. Ensures interpretation and compliance with the appropriate accrediting and regulatory agencies, while developing and maintaining a working knowledge of the statues and laws relating to credentialing. Responsible for the accuracy and integrity of the credentialing database systems and related applications. Works under the supervision of the Contract Implementation Manager.
- Leads, coordinates, and monitors the review and analysis of pharmacy and practitioner applications and accompanying documents, ensuring applicant eligibility.
- Conducts research and primary source verification of all components of the application.
- Identifies issues that require additional investigation and evaluation, validates any sanctions and ensures appropriate follow up.
- Prepares credentials for all payers ensuring completion.
- Responds to inquiries from all payers and also interfaces with internal and external customers on day-to-day credentialing and issues as they arise.
- Assists with managed care credentialing audits; conducts internal file audits.
- Utilizes the NCPDP and CAQH credentialing database, optimizing efficiency, and performs query, report and document generation; submits and retrieves National Practitioner Database reports in accordance with Health Care Quality Improvement Act.
- Monitors initial, re-credentialing applications for all pharmacies, infusion clinics, Allied Health Professional staff, ensuring compliance with regulatory bodies.
- Performs miscellaneous job-related duties as assigned.
- Maintains copies of current state licenses, DEA certificates, malpractice coverage and any other required credentialing documents for all providers / pharmacies.
- Sets up and maintains provider information in online credentialing databases and system.
- High school diploma or GED; required
- Six (6) years of experience in the medical field, requires with a minimum of four (4) years directly related to Managed Care credentialing, preferred.
- Certification/Licensure NAMSS Certification as a Certified Professional Medical Services Manager (CPMSM) or Certified Provider Credentials Specialist (CPCS) or actively pursuing certification, preferred.
- Completed degree(s) from an accredited institution that are above the minimum education requirement may be substituted for experience on a year for year basis.
About our Line of Business
Amerita is a specialty infusion company focused on providing complex pharmaceutical products and clinical services to patients outside of the hospital. Committed to excellent service, our vision is to combine the administrative efficiencies of a large organization with the flexibility, responsiveness and entrepreneurial spirit of a local provider. For more information about Amerita, please visit www.ameritaiv.com
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