Credentialing Representative

Highmark Health

111d • $20 - $29

About The Position

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.

Requirements

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

Nice To Haves

• 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.

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.

Benefits

• 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.

What This Job Offers

• Education Level: High school or GED
• Number of Employees: 5,001-10,000 employees