Credentialing Specialist

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POSITION SUMMARY:

The Credentialing Specialist is responsible for leading and managing all aspects of the credentialing and re-credentialing processes for a specialty pharmacy organization. This role ensures compliance with PBM, health plan, accreditation, and regulatory requirements, playing a key role in network access, payer onboarding, and pharmacy readiness. The ideal candidate has in-depth knowledge of credentialing standards across PBMs, and commercial/government health plans and understands the complex regulatory and operational environment of specialty pharmacy services

ESSENTIAL RESPONSIBILITIES/DUTIES:

• Lead the end-to-end credentialing and recredentialing processes for specialty pharmacies housed within hospital or integrated delivery network (IDN) environments
• Prepare, track, and manage credentialing submissions for major PBMs (e.g Express Scripts, OptumRx, CVS Caremark) and national, regional, and Medicaid/Medicare Advantage health plans
• Ensure compliance with 340B program requirements that are tied to the payor, including eligibility entity status, contract pharmacy relationships, with pharmacy operations support
• Collaborate with Pharmacy Operations, Compliance, Legal, and Business Development to support payer network participation and maintain active provider status
• Develop and maintain a centralized credentialing database and credential files, ensuring real-time updates and document integrity
• Maintain current knowledge of regulatory and industry changes affecting credentialing and payer enrollment requirements
• Identify process improvements and implement the best practices to streamline credentialing timelines and reduce errors within the organization
• Assist with payer enrollment processes for new pharmacy locations or service expansions
• Support pharmacy onboarding and integration with new payor networks, systems, and payer portals

JOB REQUIREMENTS:

Required Education and experience:

• Bachelor’s degree or equivalent combination of education/experience
• 5 years’ experience in healthcare credentialing with at least 2 specifics to PBMs and health plans
• Familiarity with CAQH ProView, NPPES, PECOS, and Medicare/Medicaid enrollment portals
• Working knowledge of specialty pharmacy operations, licensing, and payer network participation

Preferred Education of experience: (If none, please enter N/A)

• Experience supporting specialty pharmacy services for oncology, immunology, or rare diseases
• Knowledge of IRA (Inflation Reduction Act) implications on Medicare-related credentialing.

CERTIFICATES, LICENSES, REGISTRATIONS:

Required certificates, licenses, or registrations:

N/A

Preferred certificates, licenses or registrations

Certified provider credentialing specialist (CPCS)

KNOWLEDGE / SKILLS / ABILITY:

1. Working understanding of 340b drug pricing program guidelines

2. Strong familiarity with NCQA and ACHC/URAC standards

3. Ability to interpret and apply multi-state regulation and credentialing requirements

4. Excellent organizational, time management and problem-solving skills

5. Professional written and verbal communication skills

6. Proficiency in credentialing software and Microsoft Office suite

7. Ability to manage confidential and sensitive information with discretion

SPECIAL WORKING CONDITIONS (ON-CALL, TRAVEL, SHIFT, COVERAGE):

10% in any given year for potential client-site travel or team meeting