Healthcare Provider Data Domain Expert

Purpose:
Bring real-world understanding of how provider data flows from providers to payers. Help the tech team avoid bad assumptions and define what s practical when designing AI and dual-system workflows.

Key Responsibilities:

• Explain how provider data typically flows from:
• Individual providers, group practices, CAQH, NPPES to payers.
• Define real-world provider lifecycle events:
• Onboarding, re-credentialing, terminations, address/specialty updates.
• Identify common operational pain points:
• Duplicates, outdated credentials, slow syncs, mismatches across systems.
• Help assess what AI can realistically automate vs. where human judgment is required.
• Validate assumptions in the solution design and flag compliance or usability concerns.

Must-Have Skills:

• working in provider data operations or credentialing at a health plan, MSO, or vendor.
• Deep knowledge of CAQH workflows, NPPES, NCQA/CMS directory requirements.
• Familiarity with how provider data is consumed downstream (CRM, Claims, Portals).
• Strong communication skills to advise engineers clearly on edge cases and operational reality.