Director, Provider Credentialing & Payer Enrollment

Privia Health™ is a national physician platform transforming the healthcare delivery experience. We provide tailored solutions for physicians and providers, creating value and securing their future. Through high-performance physician groups, accountable care organizations, and population health management programs, Privia works in partnership with health plans, health systems, and employers to better align reimbursements to quality and outcomes.

Reporting to the AVP of Credentialing, the Director, Provider Credentialing and Payer 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. 

Essential Functions:

• 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 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.

• 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.

Minimum Qualifications:

• 7-10 years’ 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 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.

• High level of executive presence, ability to present complex information in a concise and clear manner to allow for appropriate decision making by market leaders and other senior leadership.

• 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

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; and taste or smell. The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus.

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

Technical Requirements (for remote workers):

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 https://www.speedtest.net/. 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.

Technical Requirements (for remote workers):

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 https://www.speedtest.net/. 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.