Manager, Licensing & Credentialing

Manager, Licensing & Credentialing Omnicell - 3.4 Grapevine, TX Job Details 1 day ago Qualifications Negotiation Full Job Description Remote Manager, Licensing & Credentialing Grapevine, TX, United States Job Description Job ID 5192 Date posted 04/24/2026 Business Unit Specialty Pharmacy Work Location Type Remote Manager, Licensing & Credentialing The Manager of Payor Operations will lead the coordination and management of all aspects of PBM/Payor operations and requirements. This individual will be responsible for overseeing the end-to-end processes of payor credentialing, network enrollment, audits, claims issues, and reimbursement resolution. The ideal candidate will have strong expertise in pharmacy benefit management (PBM), pharmacy administration, payor credentialing, payor audits, and claims adjudication. This role is critical to our overall service and offerings to pharmacies. We are looking for a well-rounded member to join our team that is seasoned, experienced and knowledgeable in all aspects of payor operations. This job description is a broad outline of key responsibilities and qualifications, but it is not exhaustive. The Payor Operations Manager may be asked to take on additional tasks as needed to support the organization's overall goals and success.

ESSENTIAL FUNCTIONS

Key Responsibilities Payor Credentialing & Network Enrollment:

Lead and manage the payor credentialing and re-credentialing processes for pharmacies. Ensure accurate and timely enrollment of pharmacies with payors, including commercial, Medicare, and Medicaid plans. Maintain a comprehensive understanding of the payor enrollment requirements for various insurance carriers. Work with internal teams to ensure pharmacies are properly enrolled and compliant with payor requirements.

Audits & Compliance:

Manage and support audit activities from payors, including overseeing internal audit preparation, documentation, and communications with payor representatives. Monitor compliance with payor contracts and regulatory requirements, ensuring adherence to all applicable laws and guidelines. Ensure that audits are completed in a timely manner, including managing audit responses and ensuring corrective actions are taken where necessary. Communicate with and educate pharmacy personnel on audit processes and strategies to improve audit results.

Claim Issues & Resolution:

Oversee the investigation and resolution of pharmacy claims issues, including rejected claims, payment discrepancies, and other billing issues. Work closely with payor representatives and pharmacy teams to ensure claims are processed correctly and any discrepancies are addressed. Collaborate with the billing department and pharmacy teams to resolve any outstanding issues, minimizing financial impact on the organization.

Reimbursement Resolution:

Oversee the resolution of reimbursement issues, including negotiating adjustments or reprocessing of claims when necessary. Develop and implement strategies to maximize reimbursement for pharmacies. Work with finance and contract management teams to ensure accurate reimbursement and payment reconciliation.

Team Collaboration:

Foster strong working relationships with internal teams (e.g., operations, finance, legal) and external payors to ensure smooth communication and issue resolution. Collaborate with leadership to develop process improvements and drive operational efficiencies.

Reporting & Analysis:

Regularly track and report on key metrics such as credentialing status, audit outcomes, claim rejection rates, and reimbursement trends. Analyze trends and provide insights and recommendations to senior management regarding payor performance and network performance. Present findings to leadership and stakeholders.

Compliance & Quality Assurance:

Ensure adherence to federal, state, and payor-specific regulations for pharmacy credentialing and operations. Implement quality assurance measures to maintain data accuracy and operational compliance. Conduct regular audits to identify gaps and mitigate risk. Manage fulfillment of all requirements, including with State and Federal agencies to include credentialing for all existing pharmacy locations. Oversee all processes related to the organization, maintenance, and verification of the credentialing for pharmacy customers. Communicating new credentialing requirements as the same are introduced, such as those specific to Specialty fulfillment, heat zones, etc.

EDUCATION AND EXPERIENCE

Basic Requirements 7 + years of experience in payor credentialing, payor operations, network enrollment, claims adjudication, reimbursement, or pharmacy audit (Required) 5+ years of experience in payor relations, pharmacy operations, specialty pharmacy, or healthcare payor management (Required) Prior experience working with pharmacy benefit managers (PBMs), insurance companies, or a PSAO (Required) Specialty pharmacy experience (Required) PSAO knowledge and experience (Required) Active Nationally Certified Pharmacy Technician (CPhT): PTCB or NHA accepted. (Required) Additional Requirements Travel up to 30% (Required) Preferred Qualifications Associate's or Bachelor's degree in Healthcare or a related field Thorough knowledge of state and federal regulatory guidelines related to pharmacy Skills & Knowledge Strong understanding of payor credentialing, PBM operations, pharmacy administration, regulatory requirements, payor audits, reimbursement policies, PBM contracts, and payor networks Excellent problem-solving skills with the ability to resolve complex claim and reimbursement issues Strong communication and analytical skills Ability to manage multiple priorities in a fast-paced environment Exceptional communication and negotiation skills to collaborate with internal teams and external stakeholders Proficiency in Microsoft Office Suite (especially Excel) Experience with credentialing portals and pharmacy management systems Key Performance Indicators (KPIs) Timeliness of pharmacy credentialing and re-credentialing submissions Accuracy and completeness of pharmacy payor enrollment and data Turnaround time for resolving payor/PBM issues

COMPETENCIES

Demonstrates initiative, professionalism, punctuality, and efficiency Ability to multitask and perform well under pressure in both remote and in-office environments Proactive, responsive, and resourceful with strong follow-up and organizational skills Flexible and motivated, with the ability to work independently and within a team Strong interpersonal skills with the ability to engage effectively across all levels of the organization Excellent computer skills in a Microsoft Windows environment Maintains a high level of confidentiality and discretion Ability to execute on strategic plans and drive results Builds and leverages key relationships Strong problem-solving, analytical, and strategic thinking capabilities Demonstrates technical proficiency, integrity, and motivation EEO, Privacy, and Adaptability Omnicell welcomes applications from all individuals, valuing a wide range of perspectives and backgrounds. As an equal opportunity employer, we do not discriminate based on race, gender, religion, sexual orientation, gender identity, national origin, veteran status, or disability. We are committed to making our recruitment process accessible to everyone. We offer support and reasonable adjustments for individuals with disabilities during our hiring process. If you need assistance, please contact us at . At Omnicell, respect for privacy and confidentiality is paramount. We adhere to strict policies to prevent discrimination or retaliation against those who engage in open conversations about compensation. However, employees privy to compensation information as part of their job role are expected to maintain confidentiality, except in specific circumstances outlined by law, such as during formal complaints, investigations, or as required by legal obligations. Learn more about our privacy practices: https://www.omnicell.com/privacy/ Please note that Omnicell reserves the right to modify job roles and responsibilities as needed to meet our organization's evolving needs and drive our mission forward. About Us At Omnicell, innovation starts with people who are passionate about making healthcare safer and smarter. Since 1992, we've been transforming the future of pharmacy care through bold ideas and hands-on solutions that make a real impact on clinicians and patients' lives. We build outcomes-driven technology—from robotics to intelligent software—that helps clinicians work more efficiently and ensures patients get the care they need. Every improvement, every breakthrough, every idea is rooted in our belief that better is always possible. But what sets us apart isn't just the work we do, it's how we do it. Our Culture of Care shapes everything, from how we show up for each other to how we solve tough problems together. You'll find a team that has your back, leaders who listen, and a shared commitment to building something that matters. Here, careers are more than job titles, they are journeys of purpose and possibility. Whether you're just getting started or ready to grow in new directions, we'll meet you where you are, with support, flexibility, and opportunity that matches your ambition. If you're driven by purpose and ready to shape what's next in healthcare, there's a place for you at Omnicell.