Credentialing & Delegation Compliance Analyst

Highmark; United States; On-site; USD 32,000 - 49,000; Full time

Job summary

Highmark Inc. seeks a Credentialing Program Coordinator to coordinate and maintain a delegated credentialing program in line with GHP, NCQA and regulatory standards.

The role covers pre-delegation assessments, annual oversight audits, and ongoing monitoring of recommendations and work plans, along with managing delegation agreements. You will implement GHP programs, monitor performance against contract standards, and develop corrective action plans.

Qualifications

• High school diploma / GED required.
• 3 years of experience 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.

Responsibilities

• Implement GHP Programs.
• Facilitate problem resolution when needed.
• Provide daily oversight of credentialing delegates to ensure delegated entities meet NCQA, DPW, and DOH policies and procedures.
• Establish and monitor processes to evaluate performance against contract standards.
• Identify opportunities for improvement and facilitate problem resolution.
• Develop and monitor corrective action plans for delegates.
• Prepare evaluation reports on delegate performance and issues.
• Develop communication with other GHP Departments to resolve barriers.
• Ensure data collection and submission mechanisms are in place.
• Analyze reports for timeliness and generate reports on request.
• Attend delegation and GHP Committee meetings and external meetings related to delegated services.
• Other duties as assigned.

Education

High school diploma / GED

Bachelor’s degree

CPCS certification

Job description

Highmark Inc. seeks a Credentialing Program Coordinator to coordinate and maintain a delegated credentialing program in line with GHP, NCQA and regulatory standards.

The role covers pre-delegation assessments, annual oversight audits, and ongoing monitoring of recommendations and work plans, along with managing delegation agreements. You will implement GHP programs, monitor performance against contract standards, and develop corrective action plans.