Previous Job
Previous
Network Credentialing Specialist
Ref No.: 18-21327
Location: Philadelphia, Pennsylvania
The primary purpose of the job is to:

• Tracking and monitoring pharmacy credentials to ensure compliance with plan standards, accreditation agencies and state and federal regulatory guidelines. Issuing notification to pharmacies when there are lapses in compliance information. Maintaining up to date credentialing on Pharmacies to ensure contract compliance.
• Executing updated Pharmacy contract drug rate information. Ensuring contracted rates are properly recorded and communicated within the Argus and the data bases. Ensuring integrity is maintained within various data, i.e. Argus SNA and the Access database. Reviewing, mailing and communicating with Pharmacy staff on new contracts and other issues as they arise.
• Validating Argus SNA system and IPNS to ensure contracted rates are reelected within the claims processing system. Updating information against the NCPDP file for address, new and closed pharmacies, and other key metric information as needed.
• Reporting key Pharmacy metric information regarding credentials. Work with contracting to suspend/ remove from network any pharmacies not meeting credential requirements.
• Manage and monitor each client network structure with the Pharmacy Network database, SNA and IPNS.
• Responding to Pharmacy complaints by researching and communicating issues to internal groups or escalating according to department and company policy. Providing explanations on claim status, policy changes and payment decisions. Coordinating activities impacting inter/intra departments to ensure smooth coordination of members related inquiries.
• Maintains proactive and effective communication with all members of the departmental team and communicates any concerns appropriate staff immediately. Continuously evaluates administrative operational procedures and recommends changes as appropriate
• Performs other related duties and projects as assigned. Including communications to Pharmacies and other related entities as needed. Participating in executed contract activities as needed. Attends required training as necessary.
• Supports and carries out the Mercy Mission & Values. Adheres to AMFC policies and procedures. Maintains a current knowledge base of program services, policy and procedures. Regularly reviews and reacts to policy updates and departmental procedures.
• Creates and supports an environment which fosters teamwork, cooperation, respect and diversity. Establishes and maintains positive communication and professional demeanor with employees and clients at all times. Demonstrates and supports commitment to corporate goals and mission.

Job related experience.
High School Diploma or GED Required
Associate's Degree Preferred
Healthcare knowledge
Previous customer service experience in a managed care environment.