Summary
The OSPS Credentialing and Audit Coordinator plays a key role in supporting the Client Services team by managing pharmacy credentialing activities, coordinating responses to PBM and third-party audits, and resolving payor-related issues. This role supports compliance, reimbursement optimization, and strategic initiatives across the organization.
Essential Functions
- Support the coordination and timely response to PBM and third-party audits, ensuring all requests are reviewed and addressed within required deadlines
- Prepare and organize audit responses and assist with appeal submissions when applicable
- Collect, review, and validate audit documentation from pharmacies to ensure accuracy and completeness prior to submission
- Assist with PBM-related activities, including MAC appeals, claim rejections, and reimbursement discrepancies
- Maintain active pharmacy credentialing with all required entities in compliance with regulatory and contractual requirements
- Communicate with PBMs to verify contracted reimbursement rates and initiate appeals as needed
- Maintain and audit contract and carrier code data within the third-party reconciliation system to ensure financial accuracy
- Manage and analyze the Daily Rejection Report and investigate and resolve third-party claim rejections
- Collaborate with Accounting, Finance, and Operations teams to support accurate reporting and resolution of audit findings and pricing discrepancies
- Support formal communications with Pharmacy Benefit Managers and Managed Care Organizations
- Perform additional duties as assigned to support departmental and organizational objectives
Education And Experience
Required Qualifications
- Certified Pharmacy Technician registration
- Minimum of 5 years of experience working in a specialty pharmacy environment
Preferred Qualifications
- 2 to 3 years of experience working in a pharmacy dispensing system
- Experience with PBM or payor audits
Competencies And Skills
- Strong attention to detail with excellent organizational and time management skills
- Effective communication and interpersonal skills, including the ability to perform well in high-pressure situations
- Ability to manage multiple priorities in a fast-paced environment
- Strong analytical and problem-solving skills related to claims and reimbursement issues
- Proficiency in Microsoft Office applications
- Self-motivated, proactive, and resourceful with strong follow-through
- Ability to work independently and collaboratively within a team environment
- Professional demeanor with a strong work ethic and commitment to accuracy
- Ability to interact effectively with internal teams, clients, and external partners at all levels
- Ability to work remotely or in an office environment
- Willingness to travel up to 25% as needed
PAY RANGE
The targeted pay range for this position is $58,000 to $60,000 annually.
The final offer will be based on factors such as qualifications, experience, geographic location, and internal equity, and may vary within the stated range.
