Job Description :
The incumbent supports provider account support 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 and outputs and any subsequent requirements. The incumbent may have direct interaction with providers, provider offices, billing agents, provider representatives, management and internal staff. The position ensures compliance with National Committee on Quality Assurance (NCQA), CMS, DOH regulations, BCBS, internal and private business audits in the provider data management space. The incumbent is responsible for contract administration – inclusive of, but not limited to, contract generation, reviewing signed contracts, updating provider file and executing contract.
- Responsible to review contracts, as applicable, to ensure there are no changes, secure and execute standard provider contracts, materials, and information as required for the development of provider networks. Maintain credentialing compliance, also handling all error management and ensure files are corrected. Ensure compliance with terms of the provider contracts, file maintenance and credentialing guidelines. Ensure compliance with the following agencies, Federal Government, NCQA and CMS standards are met, American Healthcare Commissions URAC standards within the scope of West Virginia (WV), Delaware (DE), Pennsylvania (PA) and New York (NY) contracts. Department of Labor (DOL), Department of Health (DOH) and/or the Insurance Department. Other agencies include, HIPAA, DMMA, HEDIS, BCBSA and Highmark Health Services and all its affiliates’ operational and Corporate policies.
- Provide support and input in system testing, User Acceptance Testing, business requirements, and test cases. Mentor peers and PIM representatives at all levels. Assist management in root cause analysis. Present at staff meetings.
- Interact with all levels of management to analyze provider file issues, network status, claims, directory. Prioritize and reprioritize work based on current priorities.
- Analyze corrective updates from various quality control reports to ensure provider data accurately reflects current data. Follow guidelines in support of BCBS requirements and maintain strict confidentiality of all information, which requires the integrity and proper handling of all confidential materials.
- Resolve inquiries and provide quality interactions with providers and internal and external entities/organizations to ensure all telephone or written inquiries received are handled promptly, accurately and consistent with department standards and in compliance with all regulating bodies/agencies, documenting information accurately using internal inquiry tracking systems or credentialing database. This position will display communications with varied sources which are not limited to, provider offices, billing agents, provider representatives, management and internal staff.
- Contact external sources to collect or clarify information or documentation which in turn must be reviewed and evaluated against the established guidelines, policies and procedures to ensure the file meets all policy and procedures in conjunctions with regulations. This specialist must ensure the data in CPR and HC3 are accurate and system compatible.
- Load and maintain provider demographic information and credentialing files, as well as load and maintain provider primary source verification information in HC3, the credentialing, contracting and communication system.
- Other duties as assigned or requested.
- High School Diploma/GED
- Bachelor's Degree
- 7 years in a service role, in any industry involving customer support or related field
- 5 years of Operations Support
- 5 years in Customer Service
- 5 years with Provider Credentialing
- 5 years in Provider Service
- Oral and Written Communication Skills
- Digital Skills
- Company Culture
- Critical Thinking
- Problem Solving
- Decision Making
- Analytical Skills
- Understands fundamental principles, concepts, practices and processes within a specific field or discipline
- This individual must possess a high accuracy level while applying complex and detailed guideline to multiple increments of work.
- Proficient in PC skills, word processing software, accessing the internet, web based applications and manage files.
Language (Other than English)
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Teaches / trains others regularly
Travel regularly from the office to various work sites or from site-to-site
Does Not Apply
Works primarily out-of-the office selling products/services (sales employees)
Physical work site required
Lifting: up to 10 pounds
Lifting: 10 to 25 pounds
Lifting: 25 to 50 pounds
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.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
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.
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, age, 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, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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