Sr Director, Provider Data Management & Credentialing

Alignment Health•Remote CA Outside Bay Area, CA

1d•$149,882 - $224,823

About The Position

The Senior Director, Provider Data Management (PDM) & Credentialing provides strategic leadership, governance, and operational oversight for provider data management, credentialing, network configuration support, and provider record integrity across Alignment Health. The role ensures provider information is accurate, complete, compliant, and synchronized across systems of record, and that provider data, network relationships, contract identifiers, and reimbursement structures reflect contractual intent. The position owns the end-to-end provider data lifecycle, including credentialing, network participation management, provider maintenance, data quality oversight, and distribution of data to claims, provider directories, care management, regulatory reporting, and other business functions. The Senior Director partners with Network Management, Provider Contracting, Provider Operations, Technology, Compliance, Product, Claims, Configuration, and Vendor Management teams to support organizational growth, regulatory compliance, provider satisfaction, and member experience.

Requirements

10 or more years of progressive healthcare experience in a health plan environment.
7 or more years of leadership experience in Provider Operations, Provider Data Management, Network Operations, Credentialing Operations, or a related function.
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 a 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.

Nice To Haves

Experience with NCQA accreditation requirements and CMS regulations.
Experience implementing Provider Lifecycle Management (PLM) platforms.
Knowledge of provider master data management concepts and data governance frameworks.
Experience with provider data technologies, workflow automation solutions, and digital transformation initiatives.
Lean Six Sigma, PMP, or related operational excellence certifications.
Master's degree in Healthcare Administration, Business Administration, Health Informatics, Information Systems, or a related field.

Responsibilities

Lead the enterprise provider data management function and establish governance frameworks for data quality, stewardship, and operational excellence.
Ensure provider demographic, credentialing, contracting, participation, reimbursement, and network data are accurately maintained 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 for provider data operations.
Drive continuous improvement through 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.
Ensure provider records accurately reflect contract intent, network participation status, provider-to-network relationships, contract and rate schedule identifiers, affiliations, Tax ID and billing relationships, and facility and practitioner relationships.
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 credentialing operations comply with NCQA, CMS, state regulatory, accreditation, and organizational requirements.
Monitor credentialing turnaround times, inventory, productivity, and quality outcomes.
Partner with Credentialing Committees, Medical Directors, Compliance, Legal, and Provider Network teams on provider participation decisions.
Oversee delegate vendor relationships and vendor performance management for credentialing, where applicable.
Partner with Network Management and Provider Contracting to ensure provider data accurately reflects executed contract terms.
Oversee implementation and maintenance of network relationships, participation status, contract assignments and IDs, rate IDs, product participation indicators, and geographic service areas.
Establish processes to validate that configuration aligns with contractual intent and regulatory requirements.
Collaborate with Configuration and Claims teams to minimize payment errors and operational risk related to provider setup and maintenance.
Lead teams responsible for provider data maintenance, credentialing, provider onboarding, roster management, and provider lifecycle activities.
Build scalable operating models to support membership growth, acquisitions, product launches, and network expansion.
Direct workforce planning, organizational development, resource management, performance outcomes, and employee engagement.
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.
Partner with Compliance, Legal, and Internal Audit to identify and mitigate operational risks.
Develop corrective action plans for identified gaps and ensure timely implementation.
Partner with business and technology leaders to define future-state provider lifecycle management capabilities.
Drive modernization involving provider data platforms, credentialing systems, workflow automation, AI-enabled processes, and provider directory solutions.
Support business case development and vendor evaluations for provider lifecycle transformation.
Lead implementations that improve data accuracy, operational efficiency, provider experience, and organizational scalability.