Senior Director, Provider Data Management – Credentialing

This is a fully remote position, open to applicants in United States.

📋 Description

• Oversee the enterprise provider data management function and create governance frameworks that enhance data quality, stewardship, and operational excellence.

• Ensure the accurate maintenance of provider demographic, credentialing, contracting, participation, reimbursement, and network data across both source systems and downstream platforms.

• Define data ownership, implement controls, establish audit processes, and create policies that govern provider information throughout their lifecycle.

• Develop and track KPIs, SLAs, and quality metrics associated with provider data operations.

• Propel initiatives focused on automation, process optimization, data quality enhancement, and operational efficiency.

• Maintain uniformity and synchronization among provider systems of record, credentialing platforms, contract management systems, network configuration tools, claims platforms, provider directories, and regulatory reporting solutions.

• Implement controls to detect and prevent discrepancies between source systems and downstream consumers.

• Lead the resolution of data quality issues impacting claims payment accuracy, provider directories, member access, and regulatory compliance.

• Manage the complete credentialing and recredentialing processes for participating providers and facilities.

• Ensure adherence to NCQA, CMS, state regulatory, accreditation, and organizational standards.

• Monitor credentialing turnaround times, inventory management, productivity, and quality outcomes.

• Collaborate with credentialing committees, medical directors, Compliance, Legal, Provider Network, Network Management, Provider Contracting, Technology, Product, Claims, Configuration, and Vendor Management teams.

• Guarantee that provider data reflects executed contract terms, network relationships, participation status, contract assignments, contract IDs, rate IDs, product participation indicators, and geographic service areas accurately.

• Lead teams responsible for provider data maintenance, credentialing operations, provider onboarding, roster management, and provider lifecycle management.

• Develop scalable operational models to support membership growth, acquisitions, new product launches, and network expansion.

• Direct workforce planning, organizational development, resource management, performance outcomes, and employee engagement initiatives.

• Promote accountability, quality, transparency, and a culture of continuous improvement.

• Prepare for NCQA, CMS, state regulatory audits, accreditation reviews, and internal compliance assessments.

• Oversee provider directory accuracy and compliance programs related to provider data.

• Create corrective action plans and ensure their timely execution.

• Define future-state provider lifecycle management capabilities in collaboration with business and technology leaders.

• Drive modernization efforts involving provider data platforms, credentialing systems, workflow automation, AI-enabled operational processes, and provider directory solutions.

• Assist in the development of business cases and vendor evaluations.

• Lead implementation initiatives that enhance data accuracy, operational efficiency, provider experience, and organizational scalability.

⛳️ Requirements

• 10+ years of progressive experience in healthcare within a health plan environment.

• 7+ years of leadership experience in Provider Operations, Provider Data Management, Network Operations, Credentialing Operations, or similar fields.

• Proven experience managing provider data across various systems and source-of-truth environments.

• Experience in supporting contract implementation, provider network setup, contract IDs, reimbursement structures, and rate schedule management.

• Bachelor's degree in Healthcare Administration, Business Administration, Health Informatics, Information Systems, or a related discipline.

• In-depth knowledge of provider lifecycle management processes and health plan operations.

• Extensive understanding of provider contracting, network operations, credentialing and recredentialing, provider enrollment, provider directory management, claims operations, network configuration, and regulatory compliance requirements.

• Strong analytical, operational, and problem-solving skills.

• Demonstrated ability to lead large-scale operational transformation and process improvement projects.

• Preferred: Experience with NCQA accreditation requirements and CMS regulations.

• Preferred: Experience in implementing Provider Lifecycle Management (PLM) platforms.

• Preferred: Familiarity with provider master data management concepts and data governance frameworks.

• Preferred: Experience with provider data technologies, workflow automation solutions, and digital transformation initiatives.

• Preferred: Lean Six Sigma, PMP, or other relevant operational excellence certifications.

🏝️ Benefits

• Comprehensive healthcare coverage.

• Competitive salary and performance bonuses.

• Opportunities for professional development and training.

• Flexible working hours and a supportive work environment.

• Paid time off and holiday benefits.