Credentialing Representative

Highmark Health • Carolina, PA

6d • Onsite

About The Position

This job processes provider applications and re-applications including initial mailing, review, and loading. It maintains the provider database and communicates with providers regarding credentialing status and information. The role performs credentialing, re-credentialing, and related activities, and coordinates credentialing verifications. It reviews and processes complex additions, updates, and deletions of provider information in the Dental Provider file database. The position supports the implementation of new networks, systems, software, and guidelines, with a focus on group practices. Depending on the level, it may train credentialing personnel and participate in projects to streamline or 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.)
• 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.

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-credentials providers.
• Contacts providers or representatives by telephone or in writing to obtain additional information while processing their enrollment applications.
• Screens incoming applications and paperwork for completeness and accuracy and sends necessary paperwork to the credentialing vendor.
• Performs credentialing verifications and loads provider to appropriate networks and credentialing information to the provider database.
• Manages credentialing inventory, reports, and projects to ensure all established time frames for completing work, reports, and projects are met.
• Depending on level, trains credentialing team in the use of various systems, software, databases, processes, and procedures.
• Creates and distributes monthly reports as assigned and handles complex and unusual or high-level credentialing issues.
• Supports projects, audits, business partners, internal departments, and external clients.
• Represents the department as the Subject Matter Expert.
• Pulls and researches necessary documentation for audits.
• Supports updates necessitated by business partners, internal departments, and external clients.
• Provides customer oversight for customers who have unique requirements and timelines to ensure compliance.
• Depending on level, investigates interim license actions.
• Participates in projects which streamline, automate, or otherwise enhance credentialing functions.
• Other duties as assigned or requested.

Benefits

• 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED