Full-Time Manager, Provider Credentialing (NCQA)

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
• Maintains a strong, working knowledge of the credentialing database and associated systems to serve as a subject matter expert and troubleshoot issues for the team.
• Provides necessary administrative and operational backup/support to coordinators and the director, including performing system backups, running ad hoc reports, and processing credentialing files as requested to ensure continuous workflow.
• Comprehensive knowledge of NCQA (or equivalent) standards in credentialing as well other state and regulatory licensure requirements
• 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 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+ years’ experience in managed care credentialing, billing and/or Medical Staff service setting required

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