Join PacificSource and help our members access quality, affordable care!
PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.
Responsible for leading provider credentialing, recredentialing, and provider data management operations across PacificSource. Ensures compliance with regulatory and accreditation requirements (e.g., NCQA), maintains provider data integrity, and drives operational excellence across credentialing and provider data functions. Partner cross-functionally to support organizational goals, improve processes, and enhance data quality and reporting with a strong focus on data optimization, extraction, and taxonomy for current and future business needs across all lines of business. Demonstrate effective leadership by developing teamwork and team support, managing change and encouraging innovation, building collaborative relationships, encouraging involvement and initiative, and developing increased vision and commitment to goals.
Essential Responsibilities:
- Responsible for hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees. Provide feedback, including regular one-on-ones and performance evaluations, for direct reports.
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Responsible for positive departmental culture as it relates to following and modelling company values and identifying and pursuing improvements based on employee engagement survey results.
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Manage daily operational performance and collaboration, as well as highlight team accomplishments.
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Develop annual department budgets. Monitor spending versus the planned budget throughout the year and take corrective action where needed.
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Develop and implement adequate programs and processes ensuring complete programs that meets or exceeds requirements.
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Lead and manage all credentialing and recredentialing operations, ensuring compliance with NCQA, regulatory, and accreditation standards; oversee credentialing committee workflows and provider approval processes.
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Direct provider data management operations, including provider setup, data integrity, database maintenance, provider directory accuracy, and processes impacting claims and encounter data.
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Oversee internal audit activities, compliance findings, corrective action plans, and reporting requirements to ensure operational and regulatory compliance.
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Design, implement, and continuously improve systems, processes, and workflows to enhance efficiency, data accuracy, and audit readiness across credentialing and provider data functions.
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Advance data strategy initiatives, including data optimization, taxonomy, extraction, and reporting capabilities to support organizational and operational needs.
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Provide oversight of site surveys and medical record review processes, including associated travel, documentation, and compliance requirements.
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Maintain and manage delegated credentialing arrangements and support accreditation efforts, including ongoing readiness for NCQA and other regulatory reviews.
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Partner cross-functionally with Provider Network Contracting, Provider Relations, and other departments to align processes, improve service delivery, and support business objectives.
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Collaborate with internal and external stakeholders, including providers and vendor partners, to ensure accurate and effective credentialing and provider data operations.
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Identify, evaluate, and implement process improvements and technology solutions, including system enhancements and vendor tools (e.g., Cactus, Facets), to optimize performance and scalability.
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Monitor operational performance through key metrics, dashboards, and continuous improvement practices (e.g., huddles, lean methodologies) to identify trends and drive outcomes.
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Evaluate provider network data and reporting to support decision-making, including network assessments and business development needs.
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Lead, coach, and develop staff, including hiring, performance management, employee engagement, and ongoing professional development.
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Ensure compliance with HIPAA and confidentiality requirements in all aspects of credentialing and provider data management activities.
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Represent the function in leadership meetings, committees, and organizational initiatives; communicate key updates and ensure alignment across teams.
Supporting Responsibilities:
- Meet department and company performance and attendance expectations.
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Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
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Perform other duties as assigned.
SUCCESS PROFILE
Work Experience: Minimum of 5 years of healthcare or healthcare operations experience required, Experience in credentialing, provider data management, or working within regulatory or accreditation environments (e.g., NCQA) is required, along with familiarity managing delegated credentialing relationships and using provider data systems such as Symplr or Facets. Prior supervisory experience is strongly preferred.
Education, Certificates, Licenses: Bachelor’s degree required. Candidates with an associate’s degree and 2 years of relevant experience, or a high school diploma and 4 years of relevant experience, in addition to the required minimum years of work experience will also be considered.
Knowledge: Advanced knowledge of provider reimbursement methodologies. Knowledge of healthcare delivery, NCQA, and HIPAA are essential. Ability to gain knowledge of PacificSource policies and procedures. Foster attitude of cooperation and professionalism with external and internal contacts. Ability to identify problems and work toward problem resolution independently, seeking guidance as needed. Attention to detail; ability to handle multiple tasks and prioritize effectively. Must show initiative in approaching projects and day-to-day work. Attendance at meetings beyond regular business hours is required. Must be proficient in Word, Excel, Databases, and credentialing software programs.
Competencies
Building Trust
Building a Successful Team
Aligning Performance for Success
Building Partnerships
Customer Focus
Continuous Improvement
Decision Making
Facilitating Change
Leveraging Diversity
Driving for Results
Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 15% of the time.
Skills:
Accountable leadership, Collaboration, Data-driven & Analytical, Delegation, Effective communication, Listening (active), Situational Leadership, Strategic Thinking
Compensation Disclaimer
The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range.
Base Range:
$90,052.16 - $157,591.26
We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:
We are committed to doing the right thing.
We are one team working toward a common goal.
We are each responsible for customer service.
We practice open communication at all levels of the company to foster individual, team and company growth.
We actively participate in efforts to improve our many communities-internally and externally.
We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
We encourage creativity, innovation, and the pursuit of excellence.
Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.
Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.
