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J183161

Associate Credentialing Representative

Gateway Health Plan

  • Company Medicaid And Medicare Advantage Plan
  • Pittsburgh, PA
  • Clinical Services
  • Full time
  • Day (United States of America)

Company :

Gateway Health Plan

Job Description : 

JOB SUMMARY

This job 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

  • Credential 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

  • 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 

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 )

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For accommodation requests, please contact HR Services Online at HRServices@highmarkhealth.org

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