Manager PIM-Credentialing

Job ID: J119086
Company: Highmark Inc
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Apr 2, 2018

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Description

JOB SUMMARY

This job directs and manages the activities of credentialing/re-credentialing of the provider networks in all regions. Ensures compliance with accreditation and state and federal regulatory requirements and adherence to stringent quality control and audit compliance standards.  Accountable for corporation’s ability to achieve and maintain provider network accrediting/regulatory compliance, to be competitive with other managed care organizations. Lead key corporate operational provider data administration, management and reporting functions.  Continuously assess and advance administrative and technology solutions keeping pace with the business landscape.


ESSENTIAL RESPONSIBILITIES

  • Manage the staff responsible for the day-to-day operations of initial and re-credentialing program in compliance with corporate and regulatory standards.  This includes coordinating the accurate and timely processing of applications for network participation from receipt of the application through committee decision. Support development of credentialing policies and establishes processes in support of these policies which ensure timely and accurate credentialing activities and establishes acceptable standards for provider compliance through data collection and evaluations.  
  • Perform administrative and personnel activities, dealing with personnel issues, and preparing strategic goals and budgets on an annual basis.
  • Implement effective quality control procedures and management reports, measures and improves processes on a routine/ongoing basis.  
  • Responsible for the execution of Highmark Health Services’ radiology privileging program with review of exception cases and presentation of appeals to the oversight committee.
  • Review standards of external monitoring agencies and oversee on-going compliance with these standards.  Manage staff responsible for operational processes supporting these standards, sanctioning, corrective action, and termination of providers.
  • Support corporate initiatives and system changes to files and databases.  Maintain effective relationships with other business partners.
  • Other duties as assigned or requested.


EDUCATION
Minimum

  • High School Diploma or equivalent

Substitutions

  •  None

Preferred

  • Bachelor’s degree

EXPERIENCE

Minimum

  • 3 years of experience in  credentialing or leading an operations team in the heathcare industry
  • 3 years of experience in the interpretation of industry and corporate rules, standards, and regulations      

Preferred

  • 3 years of experience in a leadership or management role
  • 3 years of experience in personnel management.


    KNOWLEDGE, SKILLS & ABILITIES

    • Knowledge of healthcare industry
    • Knowledge of NCQA,  CMS, Medicaid, DOH and DOI regulations
    • Experience with call center management
    • Analytical orientation, expert problem solving aptitude.

    SCOPE OF RESPONSIBILITY
    Does this role supervise/manage other employees?

    Yes          

    WORK ENVIRONMENT
    Is Travel Required?    

    Yes          

    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

    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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