Spec Credentialing I / OPEIU

Company :

Highmark Inc.

Job Description : 

Job Summary

Responsible for supporting provider account activities with the implementation and administration of provider demographic information, Credentialing, and Credentialing Compliance. This position identifies and resolves problems related to provider file set up, provider affiliations, reporting, data inputs/outputs, and any subsequent requirements. May have direct interaction with providers, provider offices, billing agents, provider representatives, management, and other internal staff. The position will ensure compliance with the National Committee on Quality Assurance (NCQA), CMS, DOH Regulations, BCBS, and internal/private business audits in the provider data management space. 

This is a bargaining unit position. The collective bargaining agreement for this position requires that candidates and employees reside in the following counties in the State of New York: Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, or Wyoming.

Duties Note: The following is not intended to be an exhaustive list of all duties required of this position.

• Verifies confidential information via subscription web sites as needed for completing the credentialing and re-credentialing process: Performs necessary queries and background checks required by regulatory agencies by accessing various agency data banks and web sites; Ensures information is appropriately tracked in system; Reviews application and information to determine if Level I, II, II based on specific level criteria; and Performs primary source verification of provider information from reports (e.g. DEA quarterly report)

• Facilitates the process for the assignment of the Council for Affordable Quality Healthcare (CAQH) as part of the credentialing process, on behalf of the provider

• Reviews provider and facility enrollment applications and certifications to obtain missing information or verification according to regulatory requirements: Contacts providers through email, phone or written correspondence utilizing template.

• Responds to identified outstanding provider and facility credentialing issues and assists in resolution: answers internal and external inquires of application status via phone and/or written correspondence; and communicates with providers regarding any step or stage of the application process.

• Prepares materials for Credentials Committee for application review, prepares data tracking reports by entering required data, assembles materials necessary for committee meetings, and ensures all applicable applications are available for review by the Medical Director.

• Interact with all levels of management to achieve company-wide goals and compliance deadlines.

• Performs all job duties efficiently, accurately and at an acceptable rate of performance.

• Performs related clerical duties

• Maintains confidentiality and adheres to HIPAA regulations.

• Delivers customer service in a professional, polite and efficient manner.

• Performs other duties of a similar nature that are necessary and not inconsistent with this position or pay grade.

Education/Experience/Skills Requirements

Required Education:
HS/GED:

Required Experience:

• Minimum of one (1) to two (2) years experience in an administrative position with deadlines or productivity/quality metric requirements.

Preferred Experience:

• One (1) or more years’ experience in a healthcare administrative support role.

• Credentialing certification from a nationally recognized organization.

Required Knowledge/Skills:

• Must meet qualifications to perform the job including satisfactory completion of all training and testing.

• Data Entry 9,000 KPH.

• Correspondence test.

• Service Representative Test

• Ability to self direct and multitask in fast paced service environment while meeting department metrics. Ability to work collaboratively as a team.

• Well organized with ability to adapt to changing office environment; exhibits attention to details and time management skills.

• Proficiency in English language skills, including spelling, punctuation and grammar, in both written and verbal communication to ensure communications are issued in a professional manner.

• Ability to effectively communicate (verbal, written and interpersonal communication) with internal and external contacts, in a professional manner.

• Working knowledge of personal computer and application software such as Microsoft Office

• Ability to utilize basic office equipment.

• Ability to ef