Manager, Credentialing & Enrollment

Privia Health • North Haven, CT

80d • $70,000 - $80,000 • Onsite

About The Position

Reporting to the VP, Population Health, the Manager, Credentialing & Enrollment is responsible for all aspects of the credentialing, re-credentialing, payer enrollment processes, data integrity and expirables for providers in Privia's high performance medical group. This position is the primary liaison for credentialing and enrollment for assigned clinics, payers, billing office, and provider related issues. This position is a working manager responsible for the completion of all credentialing and enrollment tasks for their assigned market. Assures compliance with all health plan requirements as related to the provider certification, credentialing, and enrollment. Manages and monitors activities of the department to ensure compliance with all policies/procedures and regulations. Follows protocols to ensure timely resolution and completion of payer enrollment to ensure no loss of revenue to untimely payer enrollment. 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 and enrollment 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. Processes credentialing 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. 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. Maintains up-to-date data for each provider in credentialing and enrollment databases and online systems; ensures timely renewal of licenses and certifications. In addition, the Manager is responsible for all audits to ensure that delegated credentialing entities are compliant. Coordinates and prepares reports. Ensures data integrity for all providers. Assists in oversight and completion of all delegated audits. Assists with the data validation process for rosters. Records and tracks credentialing statistics. Performs other duties as assigned.

Requirements

• 5+ years' experience in managed care credentialing/enrollment, billing, and/or Medical Staff service setting.
• Demonstrated skills in problem solving, analysis, and resolution.
• 1+ years people management experience preferred.
• Intermediate/advanced Microsoft Excel skills required.
• Experience using Verity CredentialStream strongly preferred.
• Athena EMR experience preferred.
• Experience supporting Medicare/Medicaid/Commercial Payers (State of Indiana preferred).
• Strong knowledge of NCQA guidelines & delegated payers.
• Ability to function independently and manage multiple projects.
• Compliance with HIPAA rules and regulations.

Responsibilities

• Manage all aspects of credentialing, re-credentialing, and payer enrollment processes.
• Act as the primary liaison for credentialing and enrollment for assigned clinics, payers, and billing office.
• Ensure compliance with health plan requirements related to provider certification, credentialing, and enrollment.
• Monitor department activities to ensure compliance with policies, procedures, and regulations.
• Streamline processes and workflows for the onboarding department using automation.
• Develop tools and procedures for auditing and reporting to streamline credentialing and enrollment processes.
• Oversee special projects related to delegated and non-delegated health plan requirements.
• Ensure adherence to NCQA standards in policies and procedures.
• Process credentialing files and ensure timely completion per KPIs/Metrics.
• Review monthly KPIs with associates to ensure goals are met.
• Collaborate with market implementation leaders for smooth Go Lives for new groups.
• Maintain up-to-date data for each provider in credentialing and enrollment databases.
• Coordinate and prepare reports on credentialing statistics.
• Assist in oversight and completion of delegated audits.
• Assist with data validation for rosters.

Benefits

• Medical insurance
• Dental insurance
• Vision insurance
• Life insurance
• Pet insurance
• 401K
• Paid time off
• Wellness programs
• Annual bonus targeted at 15%
• Restricted stock units

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Management of Companies and Enterprises
• Education Level: Bachelor's degree