Credential Delegation Analyst

Highmark Health; Pennsylvania; Hybrid; USD 32,000 - 49,000; Full time

Job summary

Highmark Health in Pittsburgh, PA, seeks a credentialing coordinator to oversee delegated credentialing programs in line with GHP, NCQA and regulatory standards. You will supervise pre-delegation assessments, annual audits and ongoing monitoring of recommendations and action plans.

Responsibilities include developing monitoring processes, preparing evaluation reports, coordinating with GHP departments and participating in delegated service committees to ensure compliance and timely data

Qualifications

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

Responsibilities

• Coordinate implementation and oversight of GHP credentialing programs.
• Provide daily oversight of credentialing delegates to meet NCQA, DPW, and DOH standards.
• Develop and monitor corrective action plans for delegates.
• Prepare evaluation reports on delegate performance and recommendations.
• Develop communication with other GHP departments to resolve barriers.
• Attend delegation and GHP Committee meetings and external meetings as needed.

Education

High school diploma / GED

Bachelor’s degree (preferred)

Job description

Company : Highmark Inc. 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

Pay Range Minimum: $23.16 Pay Range Maximum: $35.88 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. California Consumer Privacy Act Employees, Contractors, and Applicants Notice Highmark Health is a national, blended health organization that includes one of America’s largest Blue Cross Blue Shield insurers and a growing regional hospital and physician network. Based in Pittsburgh, Pa., Highmark Health’s 35,000 employees serve millions of customers nationwide through the nonprofit organization’s affiliated businesses, which include Highmark Inc., Allegheny Health Network, HM Insurance Group, United Concordia Dental, HM Health Solutions and HM Home & Community Services. Highmark Health’s businesses proudly serve a broad spectrum of health-related needs including health insurance, health care delivery, population health management, dental solutions, reinsurance solutions, and innovative, technology solutions.