Manager - Payer & Provider Credentialing

Company Description

Privia Health™ is a technology-driven, national physician enablement company that collaborates with medical groups, health plans, and health systems to optimize physician practices, improve patient experiences, and reward doctors for delivering high-value care in both in-person and virtual settings. The Privia Platform is led by top industry talent and exceptional physician leadership, and consists of scalable operations and end-to-end, cloud-based technology that reduces unnecessary healthcare costs, achieves better outcomes, and improves the health of patients and the well-being of providers

Job Description

Reporting to the Director, Credentialing & Enrollment, the Manager, Credentialing is responsible for all aspects of the credentialing, re-credentialing and privileging processes for all providers in Privia’s high performance medical group. 

Essential Functions:

• Assures compliance with all health plan requirements as related to the provider certification and credentialing. Manages and monitors activities of the department to ensure compliance with all policies/procedures and regulations

• Reviews and streamlines processes and workflows for the onboarding department, using automation, where appropriate

• Works with technical staff to develop tools and procedures for auditing and reporting with the goal of streamlining credentialing processes and communicating with company and external stakeholders

• Oversees special projects requiring knowledge of delegated and non-delegated health plan requirements

• Ensures that NCQA standards are being followed in policies and procedures

• Assigns associate’s files and ensures they are completed timely per KPIs/Metrics

• Reviews monthly KPIs with associates to ensure they are meeting/exceeding goals by the 15th of each month

• Manages day-to-day activity of Credentialing Specialists

• Responsible for career development and growth of entry-level employees on team

• Works closely with market implementation leaders to ensure smooth Go Lives for new groups

• Interacts with varied levels of management, physician office staff and physicians effectively to accomplish credentialing and various elements of implementation and launch

• Maintain up-to-date data for each provider in credentialing databases and online systems; ensure timely renewal of licenses and certifications. In addition, the Manager is responsible for all audits to ensure that delegated credentialing entities are compliant

• Coordinate and prepare reports

• Ensures data integrity for all providers

• Assists in oversight and completion of all delegated audits

• Assists with the data validation process for rosters

• Record and track credentialing statistics

• Perform other duties as assigned

Qualifications

• 5+ years’ experience in managed care credentialing, billing and/or Medical Staff service setting required

• Knowledge of NCQA standards

• People management experience preferred

• Demonstrated skills in problem-solving and analysis and resolution

• Must be able to function independently, possess demonstrated flexibility in multiple project management

• Must comply with HIPAA rules and regulations

Interpersonal Skills & Attributes:

• Eager to embrace the challenges and opportunities to build a Credentialing department with in a rapidly growing start-up environment.

• An individual with the ability to communicate appropriately and effectively with practitioners and providers; including sensitive and confidential information.

• An individual who is passionate about playing a key role in changing the current healthcare environment.

• High level of attention to detail with exceptional organizational skills.

• Exercise independent judgment in interpreting NCQA, Joint Commission, URAC, CMS and State Laws and regulations as they pertain to the credentials of PMG Providers

• Ability to problem solve and explore all options and to use available resources to find new and effective solutions

• Prioritize and meet deadlines on an ongoing basis to ensure timely completion according to process requirements

The salary range for this role is $70,000.00-$75,000.00 in base pay and exclusive of any bonuses or benefits. This role is also eligible for an annual bonus targeted at 15%. The base pay offered will be determined based on relevant factors such as experience, education, and geographic location.

Additional Information

All your information will be kept confidential according to EEO guidelines.

Technical Requirements (for remote workers only, not applicable for onsite/in office work):

In order to successfully work remotely, supporting our patients and providers, we require a minimum of 5 MBPS for Download Speed and 3 MBPS for the Upload Speed. This should be acquired prior to the start of your employment. The best measure of your internet speed is to use online speed tests like https://www.speedtest.net/. This gives you an update as to how fast data transfer is with your internet connection and if it meets the minimum speed requirements. Work with your internet provider if you have questions about your connection. Employees who regularly work from home offices are eligible for expense reimbursement to offset this cost.

Privia Health is committed to creating and fostering a work environment that allows and encourages you to bring your whole self to work. Privia is a better company when our people are a reflection of the communities that we serve. Our goal is to encourage people to pursue all opportunities regardless of their age, color, national origin, physical or mental (dis)ability, race, religion, gender, sex, gender identity and/or expression, marital status, veteran status, or any other characteristic protected by federal, state or local law.