Medical Payer Contracting & Credentialing Specialist in at Senderra RX Pharmacy

• High school diploma or equivalent and directly relevant healthcare administrative experience is required.
• Associate or bachelor’s degree in Healthcare Administration, Business, Health Information Management, or related field; credentialing/enrollment certification (e.g., CPCS or CPES) where relevant is preferred.

• 2+ years of hands-on experience in medical payer credentialing, provider/facility enrollment, healthcare contract administration, revenue cycle payer setup, or closely related work is required.
• Commercial and government payer applications, multistate enrollment, specialty pharmacy or medical-benefit services, and direct follow-through from application to active claims participation experience is preferred.

Position Overview:

The Medical Payer Contracting & Credentialing Specialist supports Senderra Specialty Pharmacy’s expansion of medical-benefit payer network access by coordinating payer outreach, contracting documentation, credentialing, enrollment, and implementation for assigned opportunities. Reporting to the Medical Payer Contracting & Credentialing Manager, the Specialist maintains accurate payer and facility records, follows applications through verified network activation, and collaborates with Finance, Legal, Revenue Cycle/Billing, Pharmacy Operations, Compliance, IT, and payer representatives. The role executes approved contracting workflows; negotiation strategy and final business decisions remain with authorized leadership.

Essential Skills:

• Strong written and verbal communication skills
• Works well in team environment
• Proven time management and organizational skills
• Strong analytical skills
• Proven ability to prioritize and multi-task

Characteristics:

• Self-directed
• Flexible and proactive
• Sense of urgency
• Detail oriented; catches errors early
• Ethical; respects confidentiality

Responsibilities:

Medical Payer Research & Contracting Support

• Research medical payer networks, lines of business, service eligibility, geographic requirements, contracting contacts, and application pathways; maintain a prioritized opportunity tracker under manager direction.
• Prepare letters of intent, participation inquiries, payer applications, capability materials, and supporting exhibits; document payer responses and follow-up actions.
• Coordinate collection, review, routing, and version control of medical payer agreements, amendments, fee schedules, renewals, redlines, and approvals; flag incomplete or inconsistent terms.
• Support manager-led negotiations by gathering reimbursement schedules, HCPCS/J-code coverage information, billing requirements, and contract comparisons; do not independently approve pricing or contractual commitments.

Credentialing, Enrollment & Multistate Participation

• Prepare, submit, and track facility and organizational credentialing, recredentialing, provider enrollment, revalidation, attestations, and payer-specific participation applications across assigned states and entities.
• Maintain accurate NPI, tax ID, location, DBA, ownership, pharmacy licenses, accreditation, and other payer-required records; coordinate CAQH, NPPES, PECOS, or other portals only when applicable to the entity and payer.
• Track expiration dates, missing documentation, payer follow-ups, application reference numbers, approval letters, effective dates, and renewal requirements; proactively escalate delays and participation risks.
• Distinguish submitted, credentialed, contracted, system-loaded, and claims-ready statuses; confirm active payer product participation and billing readiness with the responsible teams.

Contract Implementation & Operational Coordination

• Support medical payer go-lives by distributing approved contract terms, fee schedules, payer identifiers, covered service details, and claim-submission requirements to Revenue Cycle/Billing, IT, Clinical, and Pharmacy Operations.
• Coordinate payer enrollment corrections, location or ownership updates, roster discrepancies, rejected or denied claims related to payer setup, and fee schedule loading issues; document resolution and escalate financial or compliance risks.
• Maintain complete, access-controlled contract and credentialing files, correspondence, approvals, renewal calendars, and audit support materials in Senderra-designated repositories.
• Support internal quality checks, payer audits, and process improvements; follow established privacy, documentation, and approval controls.

Tracking, Reporting & Continuous Improvement

• Maintain a current payer-by-state contracting and credentialing tracker showing owner, submission date, stage, payer contact, next action, due date, contract status, effective date, and activation evidence.
• Prepare recurring status reports on outreach, applications, aging items, executed agreements, network activation, upcoming expirations, and issues requiring management decisions.
• Update standard operating procedures, checklists, payer requirements, templates, and lessons learned to reduce preventable deficiencies and strengthen in-house contracting capabilities.

Key Deliverables & Performance Expectations

• Accurate, complete, and timely medical payer contracting and enrollment submissions with documented follow-up.
• Up-to-date payer opportunity, contracting, credentialing, and network activation trackers.
• Proactive identification and escalation of expiring credentials, stalled applications, missing documents, and implementation barriers.
• Complete, auditable contract and credentialing records, including executed agreements and confirmed effective dates.
• Documented verification of payer system loading and billing/claims readiness before opportunities are marked active.
• Specific KPI targets will be approved by department leadership.

Working Conditions:

• Fast-paced environment.
• Requires normal vision (corrected) both close and distant.
• Requires normal hearing levels (corrected).
• Requires working at a desk to use a phone and computer for extended periods of time. Requires sitting, bending.
• Uses office equipment and machinery effectively.
• Requires normal finger dexterity for keyboarding.
• Works effectively with frequent interruptions.
• Minimal travel <5%.