Business Process Sme Provider Data Management

Role Title:
Location - East Brunswick, NJ
Location: Hybrid

• Strong technical expertise and AI depth to handle the complexity of the client's Provider360 programs.
• Extensive stakeholder management experience, particularly working with VP-level executives and senior leadership.
• Ability to act as a Chief of Staff, driving strategic initiatives, governance, and execution.
• Strong AI experience and/or exposure is required.
• Preferred candidates include Senior Consultants, Managers, or Program Leaders from Big 4 firms, Accenture, or similar consulting organizations with significant provider lifecycle and program management experience.

Key Responsibilities

Provider Data Management

• Serve as the SME for end-to-end provider data lifecycle management.
• Define and improve provider data processes including provider setup, maintenance, updates, terminations, and directory management.
• Ensure provider demographic, specialty, affiliation, and network participation data accuracy.
• Support provider data governance, quality controls, audits, and regulatory compliance initiatives.

Provider Onboarding & Contracting

• Lead provider onboarding processes from contracting through production readiness.
• Coordinate with provider network, contracting, credentialing, and operations teams to ensure timely provider setup.
• Analyze onboarding bottlenecks and recommend process improvements.
• Support provider roster management and large-scale provider data conversion efforts.

Credentialing & Recredentialing

• Provide expertise in credentialing and recredentialing workflows.
• Ensure compliance with NCQA, CMS, State, and UHC credentialing requirements.
• Support Primary Source Verification (PSV), sanction monitoring, provider enrollment, and committee review processes.
• Identify automation opportunities to improve credentialing cycle times and quality.

Pricing & Reimbursement

• Demonstrate strong understanding of provider reimbursement methodologies including:
  • Fee-for-Service (FFS)
  • Capitation
  • Value-Based Care (VBC)
  • Risk-sharing arrangements
  • Shared savings models
  • Bundled payments
• Support provider contract interpretation and pricing configuration requirements.
• Work with business and configuration teams to validate provider reimbursement rules and fee schedules.
• Analyze provider contract impacts on claims adjudication and payment accuracy.

Business Process Excellence

• Document current-state and future-state business processes.
• Lead workshops with provider operations, contracting, credentialing, and network teams.
• Identify process gaps and recommend operational improvements.
• Develop business requirements, process flows, SOPs, and training materials.
• Support transformation programs involving automation, workflow optimization, and AI-driven provider operations.

Required Qualifications

• 15+ years of healthcare payer experience.
• 10+ years focused on Provider Data Management and Provider Operations.
• Deep knowledge of:
  • Provider onboarding
  • Credentialing and recredentialing
  • Provider contracting
  • Provider directory management
  • Provider maintenance operations
  • Provider network management
• Strong understanding of payment and reimbursement methodologies including capitation and risk-based models.
• Experience working with provider lifecycle management processes and systems. Provider lifecycle processes including intake, credentialing, contracting, provider data updates, recredentialing, pricing configuration, and rate loading are foundational capabilities in payer provider operations.
• Experience gathering business requirements and translating them into operational and system solutions.
• Strong stakeholder management and communication skills.

Preferred Qualifications

• Experience supporting UnitedHealthcare, Optum, or other large payer organizations.
• Experience with Facets Provider Module, NICE, NDB, Salesforce, or provider management platforms.
• Knowledge of provider pricing configuration, rate loading, and claims adjudication impacts. Provider pricing configuration and rate loading are key provider operations functions closely tied to reimbursement setup and downstream claims processing.
• Experience with provider data quality, compliance, and regulatory reporting.
• Familiarity with AI/automation solutions in provider operations and credentialing workflows.

Desired Skills

• Provider Data Management
• Provider Credentialing & Recredentialing
• Provider Onboarding
• Provider Contracting
• Provider Pricing & Capitation
• Network Management
• Healthcare Payer Operations
• Business Process Reengineering
• Facets provider modules
• Requirements Gathering
• Process Mapping
• Data Governance
• Regulatory Compliance

Education

• Bachelor's degree in Healthcare Administration, Business, Information Systems, or related field.
• Master's degree preferred.