Business Process SME (Provider Data Management) / Chief of Staff

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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