Credentialing Representative

Job Title

Company : Highmark Inc.

Job Summary : This job processes provider applications and re-applications including initial mailing, review, and loading. Maintains provider database 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 :

• 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.

Qualifications : Minimum :

Preferred :

Knowledge, Skills and Abilities :

Scope of Responsibility :

Does this role supervise / manage other employees? No

Work Environment :

Is Travel Required? No

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.

Pay Range Minimum : $20.31

Pay Range Maximum : $29.53

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.

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.