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