Credentialing and Privileging Specialist

Highmark Health

385d

About The Position

The Credentialing and Privileging Specialist coordinates and implements credentialing and privileging activities within the Credentialing and Privileging Office. This role involves the appointment, reappointment, and ongoing verification of the Medical Staff and Allied Health Professional Staff at Allegheny Health Network (AHN). The specialist is responsible for investigating and documenting practitioner credentials, ensuring compliance with various regulatory standards, and maintaining accurate documentation for review by licensing agencies.

Requirements

• High School / GED
• 3 years of general office administration work in a business, education, or healthcare environment

Nice To Haves

• Associate's Degree
• 3 years with physician credentialing and privileging, medical education, hospital environment, health insurance or managed care
• 1 year in customer service
• Certified Provider Credentialing Specialist (CPCS) OR Certified Professional Medical Services Management (CPMSM)

Responsibilities

• Review medical staff and allied health practitioner appointment and reappointment applications for appropriateness of data against department and external requirements.
• Determine primary sources for verifications in accordance with accreditation standards and AHN entity agreements.
• Verify and document verifications as required by external standards in the practitioner file.
• Perform follow-up and second source verification as necessary.
• Verify practitioner meets criteria for requested privileges and perform focused professional practice evaluations, reappointments, changes in status or privileges, and temporary privileges as needed.
• Evaluate all verifications for discrepancies and notify supervisors of adverse or questionable responses.
• Document results of all verifications and inquiries as required by external regulatory standards.
• Maintain credential files for the Medical Staff and Allied Health Professional Staff according to Medical Staff Bylaws and regulatory agencies.
• Assist in organizing and developing monthly Credentials Committee and Allied Health Professional Subcommittee agendas.

What This Job Offers

• Job Type: Full-time
• Industry: Insurance Carriers and Related Activities
• Education Level: High school or GED