Associate Director, Credentialing & Payer Enrollment

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 Credentialing and Enrollment, the Associate Director, Credentialing and Enrollment is responsible for managing a regional team of individuals and it responsible for overseeing all aspects of the credentialing, re-credentialing and payer enrollment processes for all providers in Privia’s high performance medical group. In this role, relationship management and communication with Market Presidents are key success factors. 

Essential Functions:

• Prepare and discuss strategic goals with Market Presidents regarding all matters related to provider credentialing and payer enrollment. 
• 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.
• Manage the team of credentialing and enrollment 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. 
• Reviews and makes recommendations for technology updates, involving all necessary internal parties in the evaluation, return on investment assessment and needs analyses to ensure that our systems are fully functioning and cost efficient.
• 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 relationships with various levels of management, physician office staff and physicians effectively to accomplish credentialing and various elements of implementation and launch.
• 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 MSO facilities and PMG.
• 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.
• Manage budget for the Credentialing department, including staffing ratio analyses, recommendations for capital expenditures, market resource allocation and efficient use of funds for staff development, training and travel when necessary.
• Design and review credentialing statistics that will drive improvement and hold people accountable for results.
• Ensure that the entire team is fully trained and able to work independently to the level of their role.

Qualifications

• 5+’ experience in managed care credentialing, billing and/or Medical Staff service setting required
• Demonstrated skills in problem solving and analysis and resolution
• Must be able to function independently, possess demonstrated flexibility in multiple project management

Interpersonal Skills & Attributes:

• Eager to embrace the challenges and opportunities to build a Credentialing department within 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 effe