Director, Provider Credentialing & Enrollment (NCQA)

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 Privias high performance medical

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 companys 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 $120000.00-$135000.00 in base pay and exclusive of any bonuses or benefits (medical dental vision life and pet insurance 401K paid time off and other wellness programs). This role is also eligible for an annual bonus targeted at 20% and restricted stock units. The base pay offered will be determined based on relevant factors such as experience education and geographic location.

Additional Information :

All your information will be kept confidential according to EEO guidelines.

Technical Requirements (for remote workers only not applicable for onsite / in office work) :

In order to successfully work remotely supporting our patients and providers we require a minimum of 5 MBPS for Download Speed and 3 MBPS for the Upload Speed. This should be acquired prior to the start of your employment. The best measure of your internet speed is to use online speed tests like This gives you an update as to how fast data transfer is with your internet connection and if it meets the minimum speed requirements. Work with your internet provider if you have questions about your connection. Employees who regularly work from home offices are eligible for expense reimbursement to offset this cost.

Privia Health is committed to creating and fostering a work environment that allows and encourages you to bring your whole self to work. We understand that healthcare is local and we are better when our people are a reflection of the communities that we serve. Our goal is to encourage people to pursue all opportunities regardless of their age color national origin physical or mental (dis)ability race religion gender sex gender identity and / or expression marital status veteran status or any other characteristic protected by federal state or local law.

Remote Work : Yes

Employment Type : Full-time

Key Skills

Fundraising,Management Experience,Coaching,Analysis Skills,Strategic Planning,Team Management,Budgeting,Leadership Experience,Mentoring,Public Speaking,negotiation,Supervising Experience

Experience : years

Vacancy : 1