Credentialing and Auditing Specialist

We are currently seeking a highly organized and detail-oriented Credentialing and Auditing Specialist. The ideal candidate will be responsible for efficiently managing the credentialing process, ensuring compliance with policy standards, preparing, and conducting various audits, including clinical management program audits, operations audits, licensing and certification audits, policy, and procedure audits, reporting audits, and training audits. The Credentialing and Auditing Specialist will play a crucial role in upholding the integrity of our operations and ensuring that health system partners meet the necessary Payor standards. Additionally, the Credentialing and Auditing Specialist will collaborate with Payor, Accreditation, Clinical, Operations, and Education and Development Teams to ensure full compliance with requirements.

Job Duties:

• Reconcile and maintain patient management credentialing audits for initial and recurring credentialing for various health system partners.
• Monitor specialty pharmacy operations, procedures, policies and prepare credentialing audits for internal and external review.
• Confidently leads audit process, including, at times, direct engagement with health system partner sites.
• Prepares and presents credentialing audit findings to leadership team during and at conclusion of audits.
• Ability to contribute novel solutions to ensure efficiency and quality of the clinical management program documentation/workflow process.
• Identifies potential operational issues hindering the attainment of quality performance standards and provides issue identification and/or suggested improvements and recommendations.
• Maintains confidentiality.
• Other duties as assigned.

Experience/ Education:

• Require 3+ years or equivalent of health system specialty pharmacy experience. Preferred certified pharmacy technician.
• High School Diploma or GED required.
• Understanding of medical terminology and specialty pharmacy operations.
• Detail-oriented, independent, and able to adjust to changing priorities.
• Capacity to quickly learn details of pharmacy operations from internal experts.
• Ability to work collaboratively in a fast-paced, technical environment.
• Ability to communicate clearly and effectively with internal and external health system partner leadership.
• Proven track record of success in managing multiple projects/multiple presentation deadlines simultaneously.
• Excellent time management skills
• Ability to lead and influence both directly and indirectly.
• Strong relationship building skills.
• Strong problem-solving skills and recognized as being resourceful.
• Excellent skills with Microsoft Word and Excel.