Role: Provider Subject Matter Expert (SME) - Payer Side
Location : Remote
Module / focus area: Provider (domain and strategic)
Contract or FTE open for both
Role summary
Serve as the go-to domain expert on provider operations, contracting, credentialing, and network management for a health plan or payer organization. You will guide FACETS configuration decisions, business process design, and cross-functional initiatives from a provider-first lens.
This is a strategic, advisory role: less hands-on FACETS screen configuration, more ownership of provider domain knowledge, contract interpretation, and guidance on what should be configured and why. It is typically a senior individual contributor position within Provider Network Operations or a Payer Configuration COE.
Key responsibilities
- Act as the primary subject matter authority on the provider lifecycle: onboarding, credentialing, contracting, network adequacy, and termination
- Advise configuration and IT teams on how provider contract terms, fee schedules, and reimbursement methodologies should translate into FACETS setup
- Review and validate provider data accuracy across systems (FACETS, provider data management tools, credentialing platforms)
- Support network strategy discussions, including network adequacy, tiering, and narrow versus broad network design
- Lead root-cause analysis on provider-related claims payment discrepancies, escalations, and disputes
- Partner with Legal and Contracting teams to interpret provider agreements and ensure system configuration reflects contract intent
- Provide training and guidance to configuration analysts, claims teams, and customer service on provider-related policies
- Support regulatory and compliance audits related to provider data (CMS, NCQA, state DOI)
- Participate in vendor and system implementations, upgrades, and provider data migrations as the business and domain expert
Required qualifications
- 6+ years of experience in provider network management, provider contracting, or provider operations at a health plan or payer; workflow experience is a must
- Deep understanding of provider reimbursement methodologies (fee-for-service, capitation, value-based care, DRG, RBRVS)
- Strong knowledge of provider credentialing and NCQA/CMS credentialing standards
- Experience with FACETS or similar core administration platforms (QNXT, Xcelys) from a business or functional standpoint
- Ability to translate contract language into system and business rule requirements
- Strong analytical skills, with comfort digging into claims and provider data to identify root causes
- Experience collaborating with IT and configuration teams to bridge business and technical requirements
Preferred qualifications
- Experience with value-based care (VBC) contract design and configuration
- Familiarity with provider data management (PDM) or Master Data Management (MDM) tools
- Exposure to provider portal or provider self-service platform requirements
- Experience supporting network adequacy filings or state/CMS network reporting
- Prior experience as a Provider Configuration Analyst or Provider Contracting Manager
- Six Sigma or process improvement certification
- Experience in multi-state or multi-line-of-business payer environments (Medicare Advantage, Medicaid, Commercial, ACA)
Madhu Challa | Sr. Technical recruiter Propelsys Technologies | 4975 Preston Park Boulevard, Suite 70 West
Plano, TX 75093
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