Credentialing Representative

Company :

Highmark Inc.

Job Description : 

JOB SUMMARY

This job processes provider applications and re-applications including initial mailing, review, and loading.  Maintains provider data base and communicates with providers by phone and mail regarding credentialing status and information.  Performs credentialing, re-credentialing and related activities and coordinates credentialing verifications.  Reviews and processes more complex additions, updates and deletions of provider information in the Dental Provider file database.  Supports the implementation of new networks, systems, software, guidelines and other endeavors with a focus on “group practices” as opposed to individual providers. Depending on level, trains credentialing personnel in the use of various systems, software, databases and procedures.  Participates in projects which streamline, automate or otherwise enhance credentialing functions.

ESSENTIAL RESPONSIBILITIES: 

• Credentials and re-credential providers.
• Contact providers or representatives by telephone or in writing to obtain additional information while processing their enrollment applications.
• Screen incoming applications and paperwork for completeness and accuracy and sends necessary paperwork to credentialing vendor.
• When necessary performs credentialing verifications and loads provider to appropriate networks and credentialing information to the provider database.
• Manage credentialing inventory, reports and projects to ensure all established time frames for completing work, reports and projects are met.
• Depending on level, train credentialing team in the use of various systems, software, databases, processes and procedures.
• Create and distribute monthly reports as assigned and handle complex and unusual or high-level credentialing issues.
• Support projects, audits, business partners, internal departments and external clients.
• Represent department as the Subject Matter expert.
• Pull and research necessary documentation for audits
• Support updates necessitated by our business partners, internal departments and external clients.
• Provide customer oversight for our customers who have unique requirements and timelines to ensure compliance.
• Depending on level, investigate interim license actions.
• Participate in projects which streamline, automate, or otherwise enhance credentialing functions.
• Other duties as assigned or requested.

QUALIFICATIONS

Minimum

• High School Diploma or GED
• 3-5 years of related, progressive experience. Grandfathered experience requirements effective August 2016.
• Experience in Provider Data Management, Customer Services or Claims.
• Microsoft office experience (i.e. Word, Excel, PowerPoint, etc.)

Preferred

• A familiarity with credentialing processes and the URAC standards.
• Experience in the use of ULTRA and Dental Provider File systems.
• Experience with the Customer Service inquiry system or claims processing concepts.

Knowledge, Skills and Abilities  

• Good written and verbal communication
• Proficiency in the use of the Provider file and the credentialing of providers.
• Proven diplomacy and a professional demeanor for effective communication with provider offices, internal personnel, vendors, accounts and committees.
• Strong written communication and presentation skills are essential. 

SCOPE OF RESPONSIBILITY  

Does this role supervise/manage other employees?     

No

WORK ENVIRONMENT

Is Travel Required?

No 

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. 

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum:

$20.72

Pay Range Maximum:

$30.12

Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations.  The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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