Associate Credentialing Representative

📋 Description

• • As an Associate Credentialing Representative at Highmark Health, you will play a crucial role in ensuring our network of healthcare providers is accurately and efficiently managed. This position is fundamental to maintaining the integrity of our provider database and facilitating seamless healthcare services for our members.
• • Your primary responsibility will involve the meticulous processing of provider applications and re-applications. This includes the initial mailing of necessary documentation, thorough review of submitted materials for completeness and accuracy, and the subsequent loading of verified provider information into our systems.
• • You will be the primary point of contact for providers and their representatives, communicating via phone and mail to provide updates on their credentialing status, request missing information, and clarify any discrepancies.
• • This role requires a keen eye for detail as you will perform credentialing and re-credentialing activities, ensuring all providers meet Highmark Health's standards and regulatory requirements.
• • A significant part of your day-to-day will involve coordinating credentialing verifications, working closely with internal teams and external vendors to confirm provider qualifications and affiliations.
• • You will handle the review and processing of more complex additions, updates, and deletions of provider information within our specialized Dental Provider File database, contributing to the accuracy and currency of our provider network data.
• • This position supports the strategic implementation of new networks, systems, software, and guidelines, with a particular focus on integrating group practices alongside individual providers.
• • Depending on your demonstrated aptitude and the needs of the team, you may be involved in training new credentialing personnel, guiding them through the intricacies of various systems, software, databases, and established procedures.
• • You will actively participate in projects aimed at streamlining, automating, or otherwise enhancing the efficiency and effectiveness of our credentialing functions, contributing to continuous improvement initiatives.
• • Essential duties include diligently credentialing and re-credentialing providers, ensuring compliance with all relevant standards and regulations.
• • You will proactively contact providers or their representatives by telephone or in writing to obtain any additional information required during the processing of their enrollment applications, ensuring a smooth and timely process.
• • A critical task is screening all incoming applications and associated paperwork for completeness and accuracy, and promptly forwarding necessary documentation to our credentialing vendor for further processing.
• • When necessary, you will perform detailed credentialing verifications and accurately load provider information into the appropriate networks and the central credentialing database.
• • Effective management of the credentialing inventory, reports, and ongoing projects is vital to ensure all established timeframes for completing work are consistently met.
• • You will be responsible for creating and distributing monthly reports as assigned, and for handling complex, unusual, or high-level credentialing issues with professionalism and efficiency.
• • This role involves supporting various projects, audits, business partners, internal departments, and external clients, requiring collaboration and clear communication.
• • You will represent the department as a Subject Matter Expert, providing guidance and insights on credentialing processes and policies.
• • You will be tasked with pulling and researching necessary documentation for audits, ensuring all required information is readily available and accurate.
• • Support will be provided for updates necessitated by our business partners, internal departments, and external clients, ensuring our provider data remains current and relevant.
• • You will provide specialized customer oversight for clients with unique requirements and timelines, ensuring their specific needs are met while maintaining compliance.
• • Depending on the level of the role and specific circumstances, you may be required to investigate interim license actions, ensuring all provider credentials remain valid.
• • Your participation in projects that streamline, automate, or otherwise enhance credentialing functions will be key to driving operational excellence.
• • You will perform other duties as assigned or requested, demonstrating flexibility and a commitment to supporting the team's objectives.