Company :

Job Description : 

JOB SUMMARY

This job coordinates and maintains delegated credentialing program in accordance with GHP, NCQA, and all regulatory agency standards.  This includes delegation program, policies/procedures, and all necessary compliance documentation. The incumbent coordinates, conducts, and evaluates all pre-delegation assessments, annual oversight audits, and the ongoing monitoring of recommendations and work plans. Coordinates and maintains all delegation agreements.

ESSENTIAL RESPONSIBILITIES

• Implement GHP Programs.
• Facilitate problem resolution when needed.
• Provide daily oversight of credentialing delegates to ensure that the delegated entities meet all NCQA, DPW, and DOH, policies and procedures related to GHP’s delegated program. 
• Establish and implement monitoring processes to evaluate performance against contract standards, requirements and performance expectations. 
• Identify opportunities for improvement, barriers and facilitate problem resolution when necessary.
• Develop and monitor all delegates corrective action plans to assist and ensure compliance. 
• Prepare an evaluation report of delegate performance, issues, deficiencies and recommendations for appropriate GHP personnel and committees review and approval.
• Develop communication processes with other GHP Departments to facilitate resolution of barriers identified with delegated services.
• Ensure mechanisms are in place to collect and submit required data. 
• Analyze reports for timeliness on an ongoing basis. 
• Design and generate reports based on special requests.
• Attend and participate in delegation and GHP Committee meetings.  Participate in external meetings related to the functions/activities of the delegate program or department activities.
• Other duties as assigned or requested.

QUALIFICATIONS

Required

• High school diploma /GED
• 3 years of experience required in health care/managed care
• 3 years of experience in credentialing/re-credentialing of practitioners/providers 
• 3 years of experience with NCQA and other regulatory standards

Substitutions

• None

Preferred 

• Bachelor’s degree.
• Certified Provider Credentialing Specialist (CPCS) certification

Skills

• None 

SCOPE OF RESPONSIBILITY 

Does this role supervise/manage other employees?

No

WORK ENVIRONMENT

Is Travel Required?

Yes   

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.

Pay Range Minimum:

Pay Range Maximum:

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.  The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

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.

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