Associate Credentialing Representative

Job ID: J133232
Company: Gateway Health Plan
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Oct 11, 2018

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Description

GENERAL OVERVIEW:  

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: 

1. Credentials and re-credential providers

  • Contact 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 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.
  • Creating and distributing monthly reports as assigned and handling complex and unusual or high-level credentialing issues.

2. 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.

3. Lead Team (dependent on level)

  • Identify training needs and oversee the necessary training so that all team members work to their potential. 
  • Manage accuracy of the team’s work so that team members meet the established QC standards.
  • Manage inventory at acceptable levels.
  • Mentor/coach staff to achieve established goals and meet compliance dates.
  • Coordinate information and activities with other departments.

4. Other duties as assigned or requested.

 QUALIFICATIONS:

Education, Licenses/Certifications, and Experience 

Minimum

  • High School Diploma or GED
  • 0-1 years of experience
  • 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 

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 their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

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