Senior Director, Provider Data Management – Credentialing

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🔥 6 minutes ago

🇺🇸 United States – Remote

💵 $149.9k - $224.8k / year

⏰ Full Time

🟠 Senior

👔 Director

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Alignment Health

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 2013

⚕️ Healthcare Insurance

🛡️ Insurance

🏥 Healthcare

💰 $135M Series C on 2020-03

Healthcare Insurance • Insurance • Healthcare

Alignment Health is dedicated to providing comprehensive care for Medicare members, emphasizing the needs of seniors, the chronically ill, and those who are frail. With a mission to transform senior healthcare, Alignment Health leverages a tailored care model and advanced technology to deliver high-quality, low-cost healthcare services. Their 24/7 concierge care team collaborates with trusted local providers to ensure that every member receives personalized care, reflecting the company's commitment to treating all members as valued family members.

📋 Description

• Lead the enterprise provider data management function and establish governance frameworks supporting data quality, data stewardship, and operational excellence • Ensure provider demographic, credentialing, contracting, participation, reimbursement, and network data are maintained accurately across source systems and downstream platforms • Establish data ownership, controls, audit processes, and policies governing provider information throughout the provider lifecycle • Develop and monitor KPIs, SLAs, and quality metrics related to provider data operations • Drive automation, process optimization, data quality improvement, and operational efficiency initiatives • Maintain consistency and synchronization across provider systems of record, credentialing platforms, contract management systems, network configuration tools, claims platforms, provider directories, and regulatory reporting solutions • Implement controls to prevent and identify discrepancies between source systems and downstream consumers • Lead remediation of data quality issues affecting claims payment accuracy, provider directories, member access, and regulatory compliance • Oversee end-to-end credentialing and recredentialing operations for participating providers and facilities • Ensure compliance with NCQA, CMS, state regulatory, accreditation, and organizational requirements • Monitor credentialing turnaround times, inventory management, productivity, and quality outcomes • Partner with credentialing committees, medical directors, Compliance, Legal, Provider Network, Network Management, Provider Contracting, Technology, Product, Claims, Configuration, and Vendor Management teams • Ensure provider data accurately reflects executed contract terms, network relationships, participation status, contract assignments, contract IDs, rate IDs, product participation indicators, and geographic service areas • Lead teams responsible for provider data maintenance, credentialing operations, provider onboarding, roster management, and provider lifecycle management • Build scalable operational models supporting membership growth, acquisitions, new product launches, and network expansion • Direct workforce planning, organizational development, resource management, performance outcomes, and employee engagement efforts • Foster accountability, quality, transparency, and continuous improvement • Ensure readiness for NCQA, CMS, state regulatory audits, accreditation reviews, and internal compliance assessments • Oversee provider directory accuracy and provider data compliance programs • Develop corrective action plans and ensure timely implementation • Define future-state provider lifecycle management capabilities with business and technology leaders • Drive modernization involving provider data platforms, credentialing systems, workflow automation, AI-enabled operational processes, and provider directory solutions • Support business case development and vendor evaluations • Lead implementation efforts improving data accuracy, operational efficiency, provider experience, and organizational scalability

🎯 Requirements

• 10+ years of progressive healthcare experience within a health plan environment • 7+ years of leadership experience within Provider Operations, Provider Data Management, Network Operations, Credentialing Operations, or related functions • Demonstrated experience managing provider data across multiple systems and source-of-truth environments • Experience 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 related field • Deep understanding of provider lifecycle management processes and health plan operations • Extensive knowledge 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 capabilities • Proven ability to lead large-scale operational transformation and process improvement initiatives • Preferred: Experience with NCQA accreditation requirements and CMS regulations • Preferred: Experience implementing Provider Lifecycle Management (PLM) platforms • Preferred: Knowledge of 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 related operational excellence certifications

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