Overview of the Role:
Reporting to the Associate Director, Credentialing & Enrollment, the Manager of Credentialing & Enrollment is responsible for all aspects of the credentialing, re-credentialing and privileging processes for all providers in Privia's high performance medical group.
- 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
- Manages day to day activity of Credentialing & Enrollment Specialists
- 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
- Assist in managing the flow of information between the payers, contracted MSO facilities and PMG.
- Coordinate and prepare reports
- Record and track credentialing statistics
- Perform other duties as assigned
- 5-10 years' experience in managed care credentialing, billing and/or Medical Staff service setting required
- Experience managing people 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