Credentialing Analyst
Abarca Health
- San Juan, PR
- Permanent
- Full-time
- Serve as a subject matter expert (SME) of the credentialing and recredentialing processes within the pharmacy network.
- Conduct ongoing credentialing and re-credentialing processes and ensure compliant and timely revision of all relevant applications.
- Review and ensure that all necessary licenses and credentials are verified and timely updated. This might include contacting licensing boards, reviewing enrollment applications, and obtaining information directly from providers.
- Ensure compliance with State and Federal regulations, especially those that apply to credentialing and CMS Stars Rating Program.
- Support Network Strategy team on issues and resolutions related to credentialing, contracting, enrollment, and termination of providers within the pharmacy network.
- Assist and maintain collections of data, tracking, and reporting for credentialing and third-party vendor in accordance with internal policies and procedures.
- Maintain cooperation and compliance with all regulatory and accrediting organizations.
- Create plans of action for assigned projects, including but not limited to workflow and quality improvements.
- Assist in the development and delivery of trainings related to credentialing and third-party oversight initiatives.
- Document activities, interventions, and issue resolutions according to internal policies for providers and third-party vendors.
- Assist with Network Strategies- Provider Relations projects and with training to other staff members.
- Assist with Pharmacy Complaints and Grievances as well as Medicaid Provider Enrollment
- Bachelor's Degree or Master's Degree in a related field. (In lieu of a degree, equivalent relevant work experience may be considered.)
- 3+ years of experience in Credentialing or Pharmacy Network Management.
- Experience developing and maintaining effective relationships with providers.
- Experience maintaining high level of confidentiality.
- Excellent oral and written communication skills.
- We are proud to offer a flexible hybrid work model which will require certain on-site workdays (Puerto Rico Location Only)
- Experience with Medicare Part D and Medicaid.
- Must be able to access and navigate each department at the organization's facilities.
- Sedentary work that primarily involves sitting/standing.