Location: East Brunswick, NJ (Hybrid)
Employment Type: Fulltime
Salary: Market - based on 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 Health Care Company 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, Capitation, Value-Based Care, Risk-sharing arrangements, Shared savings models, and 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, and 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.
- Experience gathering business requirements and translating them into operational and system solutions.
- Strong stakeholder management and communication skills.
Preferred Qualifications
- Experience supporting Client, 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.
- 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.
About Tanisha Systems, Inc.
Tanisha Systems, founded in 2002 in Massachusetts-USA, is a leading provider of Custom Application Development and end-to-end IT Services to clients globally. We use a client-centric engagement model that combines local on-site and off-site resources with the cost, global expertise and quality advantages of off-shore operations. We deliver Custom Application Development, Application Modernization, Business Process Outsourcing, and Professional IT Services from office locations in USA and India.
Tanisha Systems services clients in Government, Banking & Financial Markets, Insurance, Healthcare, Retail & Consumer Goods, Energy & Utilities, Life Sciences, Telecom, Manufacturing, and Transportation Industries around the globe. Our engagement model provides a flexible operational environment that empowers our clients with the right levels of control.
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