The Credentialing Auditor Manager’s responsibility will be to conduct daily audits of 100% of credentialing files to ensure compliance with NCQA standards as well as to ensure that all demographic information is present and correct in the group record.
Primary Job Duties:
Conducts daily audits of the credentialing files.
Assists with the development of corrective action steps needed when any trends are identified that need to be addressed.
Tracks and trends errors in the system and provides monthly reports to leadership with results.
Attends regularly scheduled meetings with leaders to share results and concerns based on audits.
Assists with reviews of monthly rosters for any data errors/issues and shares those results with the leadership team for action.
Makes recommendations for controls and process improvements to the leadership team.
Follows guidelines in alignment with all health plan requirements as related to the provider certification and credentialing.
Follows all CMS guidelines with regard to both individual and group enrollment, identifying areas of opportunity and sharing them with the leadership team.
Interacts with varied levels of management, physician office staff, and physicians effectively to accomplish credentialing and elements of implementation and launch.
Plans audits by understanding organization objectives, structure, policies, processes, internal controls, and external regulations. Identifies risk areas that support the policy scope and creates audit measures accordingly.
Continuously assesses the Credentialing and Enrollment compliance with company guidelines and external regulations and makes effective recommendations for process improvements.
Identifies gaps in current processes/procedures, completes an analysis, and provides recommendations for policy/procedure revisions and process improvements.
Due to the sensitive nature of quality audits, ensures that audit records and information are maintained in confidence within the Department and communicated only to affected Leadership.
Coordinate and prepare reports for the leadership team.
Record and track credentialing statistics.
Other duties as assigned.
5+ years experience in credentialing and in depth knowledge of NCQA and URAC standards.
Knowledge and experience using Verity CredentialStream software is a plus
Demonstrated skills in problem solving and analysis and resolution
Advanced Microsoft Excel skills
Must be able to function independently, possess demonstrated flexibility in multiple project management
Must comply with HIPAA rules and regulations
Prefer knowledge of EFT, ERA, EDI enrollment and claims systems.
The salary range for this role is $65,000.00-$75,000.00 in base pay and exclusive of any bonuses or benefits. This role is also eligible for an annual bonus targeted at 15%. The base pay offered will be determined based on relevant factors such as experience, education, and geographic location.
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 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.
Privia Health is committed to creating and fostering a work environment that allows and encourages you to bring your whole self to work. Privia is a better company 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.
