**Job Description :**
This job is responsible for provider file maintenance. The incumbent ensures compliance with National Committee on Quality Assurance (NCQA), CMS, DOH regulations, BCBS, internal and private business audits. The incumbent is responsible for contract administration – inclusive of, but not limited to, contract generation, reviewing signed contracts, updating provider file and executing contract. The incumbent encompasses Provider Customer Service on a rotated schedule. This provider line is specific to the file maintenance and credentialing processes.
+ Communicate effectively and professionally. This position will display communications with varied sources which are not limited to, State licensing agencies, Provider offices, billing agents, provider representatives, management and internal staff.
+ Responsible to review the contract to ensure there are no changes, secure and execute standard provider contracts, materials, and information as required for the development of provider networks. Ensure compliance with terms of the provider contracts. Ensure compliance with the 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 WV contracts. Department of Labor (DOL), Department of Health (DOH) and/or the Insurance Department. Other agencies include, HIPAA, HEDIS and Highmark Health Services and all its affiliates’ operational and Corporate policies.
+ Provide quality customer service to ensure all telephone or written inquiries received are handled promptly, accurately and consistent with department standards, documenting information accurately using internal inquiry tracking systems or credentialing database.
+ 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 maintain accurate data in corporate provider file repository (CPR) and credentialing database (HC3).
+ Provider Credentialing and File Maintenance Analysis.
+ Participate in 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, requires the utmost integrity in the discreet and proper handling of all confidential materials.
+ Other duties as assigned or requested.
+ High School Diploma/GED
+ 3 years of related, progressive experience. Exempted experience requirements effective August 2016.
+ 1 year experience in an operational support environment
+ 1 year in a customer service environment
+ 1 year of credentialing experience
+ Knowledge of all PA Ins. Dept., DOH and CMS regulations, NCQA, HEDIS, MAR and Highmark Health Services operational and corporate policies.
**LICENCES OR CERTIFICATIONS**
+ This individual must possess a high accuracy level while applying complex and detailed guideline to multiple increments of work.
+ This individual must possess the skill to multi task among several different databases at one time.
**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
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 job 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.
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Req ID: J182142
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