Director, Provider Credentialing & Enrollment (NCQA)

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 AVP of Credentialing, the Director, Credentialing and Enrollment is responsible for
managing a national team of individuals and is responsible for overseeing all aspects of the credentialing,
re-credentialing and privileging processes for all providers in Privia’s high performance medical group. In
this role, relationship management and communication with Market Presidents is a key success factor.

Job Duties:

• Oversee all aspects of Provider Credentialing and Payer Enrollment on a national level.

• Subject Matter Expert (SME) for all payer related matters and for reviewing payer or credentialing issues related to growth of the business, including researching and commenting on business development or market expansion credentialing matters.

• Work collaboratively with Payer Contracting, Revenue Cycle Management, Implementation, Performance Management, Finance, Compliance and other operational areas to ensure accurate information sharing, appropriate communication of any delays or other issues and complete reporting of performance and pertinent information for decision making.

• Manage the national team of credentialing resources to ensure consistency in hiring, training, onboarding and skill development. Maintain adequate resources to support the needs of the market.

• Assure 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.

• Oversee the teams responsible for special projects requiring knowledge of delegated and non-delegated health plan requirements.

• Train and manage the Credentialing & Enrollment leaders making sure to train and evaluate competencies and delegate responsibility appropriately.

• Manage processes that maintain up-to-date data for each provider in credentialing databases and online systems; ensure timely renewal of licenses and certifications.

• Maintain confidentiality of provider information.

• Assist in managing the flow of information between the payers, contracted Managed Service Organizations (MSOs) and PMG.

• Oversee and manage the end-to-end credentialing and payer enrollment processes specifically for all contracted Managed Service Organizations (MSOs), ensuring adherence to contractual requirements, service level agreements (SLAs), and delegated authority, where applicable. 

• Coordinate and prepare management reports.

• Create and manage continual process and quality improvement efforts related to payer enrollment, data entry, credentialing committees and all aspects related to credentialing & enrollment.

• Design and review credentialing statistics that will drive improvement and hold people accountable for results.

• Develop and execute a long-term strategic plan, in conjunction with AVP, for the Provider Enrollment and Credentialing function to align with the company's growth objectives and market expansion goals. 

• Evaluate, recommend, and manage the implementation of new technologies and systems (e.g., credentialing software, automation tools) to improve the efficiency, scalability, and accuracy of the enrollment process. 

• Ensure that the entire team is fully trained and able to work independently to the level of their role.

• Other duties as assigned.

Qualifications

• 7+ years experience in payer enrollment and/or managed care credentialing, NCQA credentialing, or delegated credentialing setting required
• Comprehensive knowledge of NCQA standards in credentialing, delegated credentialing and compliance with payers, as well other state and regulatory requirements. 
• Extensive people management experience required
• • Demonstrated skills in problem solving and analysis and resolution
• • Must be able to function independently, possess demonstrated flexibility in multiple project
• management

The salary range for this role is $120,000.00-$135,000.00 in base pay and exclusive of any bonuses or benefits (medic