Summary

The Manager of Licensing & Credentialing supports the OSPS PSAO through various functions, including but not limited to providing day-to-day management and oversight of the new pharmacy licensing and enrollment, audit, and credentialing teams. These teams are responsible for coordinating all PSAO pharmacy client payor audits, new pharmacy licensing, credentialing, and payor enrollment for both existing and new client pharmacies. This position works collaboratively with the Sales, Pharmacy Operations, Client Solutions, and Accounting Teams to ensure all client pharmacies perform at the highest level.

Essential Functions

New Pharmacy Enrollment and Credentialing Team

Manages fulfillment of all legal requirements with State and Federal agencies, including licensure for new pharmacy locations. Oversees processes related to the organization, maintenance, and verification of credentialing and licensing of new pharmacy clients. Oversees and manages NCPDP credentials for all new pharmacy locations. Communicates with New Pharmacy Teams and internal business partners on new credentialing requirements, such as those specific to Specialty fulfillment and heat zones. Oversees new pharmacy credentialing and enrollment.

PBM/Payor Contracting and Audit Team

Provides oversight of daily activities to manage new payor and PBM contracts, including strategies to ensure physician referrals can be adjudicated per network inclusion. Responsible for completing and submitting initial applications, following up on application submissions, and ongoing maintenance of State pharmacy licenses for the organization. Manages initial credentialing and maintenance of government pharmacy contracts, including Medicare and Medicaid. Establishes and maintains audit/appeal support processes for pharmacies. Communicates and educates pharmacy personnel on audit processes and strategies to improve audit results. Collaborates and builds relationships with PMA and Health System clients to support their new operations related to payor contracting. Communicates frequently with internal and external customers on pharmacy licensure status. Stays informed of changing State and Federal requirements impacting pharmacy and payor relationships.

Managerial

Develops and mentors subordinate employees, including Licensing & Credentialing Specialists and Pharmacy Audit & Credentialing Coordinators. Interviews potential candidates for subordinate positions and makes hiring decisions as needed. Provides clear goals, access to training, coaching, and feedback, ensuring effective performance management. Appraises subordinate performance through a formal review process on a quarterly basis as designated by Human Resources. Addresses escalated complaints, resolves issues, and disciplines employees as necessary. Performs duties in accordance with established SOPs and aligned with the company’s core values and customers' best interests. Other duties as assigned.

Education and Experience

Basic Requirements:

Bachelor’s degree  5+ years of experience in the pharmacy industry. Thorough knowledge of State and Federal regulatory guidelines related to pharmacy, including DEA and state board requirements. 

Preferred Qualifications:

Bachelor’s degree in Business or Healthcare Administration Experience managing a team 5+ years of experience in pharmacy regulatory compliance and/or managed care Specialty pharmacy experience Knowledge and experience with PSAO (Pharmacy Services Administrative Organizations) Experience with PBM (Pharmacy Benefit Management) audits Payor enrollment and contracting experience

Competencies

Initiative; professional in conduct and appearance; punctual and efficient. Proactive, responsive, and resourceful with excellent follow-up and organizational skills. Highly flexible and motivated, with the ability to work independently and in a team setting. Demonstrates the highest level of professionalism and discretion. Strong interpersonal skills, capable of interacting with all levels of clients, customers, and internal personnel. Receptive to instruction, with a strong customer service orientation. Excellent computer skills in a Microsoft Windows environment. Presentation skills for future and current clients. Effective in executing strategic plans. Ability to identify, develop, and leverage key relationships. Personal Effectiveness/Credibility. Problem-Solving/Analysis & Strategic Thinking. Technical Capacity, with high levels of confidence, integrity, and motivation.

Work Conditions

Willingness to travel up to 30% of the time Ability to work both on-site and remotely, as needed Ability to multi-task and work well under pressure. Must be able to exhibit a high level of confidentiality in all tasks and communications.