Healthcare Provider Data Management Lead

UST USource; Pateros; On-site; PHP 5,653,000 - 9,422,000; Full time

Job summary

UST USource is seeking a Team Lead for Provider Data Management (PDM) to oversee end-to-end data maintenance services within a BPM environment. You will lead outreach verification, returned mail resolution, credentialing updates, and PIMS claim support while ensuring data accuracy, governance, and SLA adherence.

The role requires strong leadership, process improvement mindset, and collaboration with cross-functional teams to drive continuous improvement in provider data workflows.

Qualifications

• Must have hands-on knowledge of US healthcare payer provider data management and credentialing operations.
• Experience with provider outreach, returned mail, credentialing maintenance, and PIMS claim workflows.
• Familiarity with BPM operations, SLA management, and quality governance.

Responsibilities

• Own daily Provider Data Management (PDM) delivery across outreach verification, returned mail, credentialing updates, and PIMS claim support.
• Manage work allocation, queue balancing, inventory aging, productivity, and staffing coverage.
• Ensure updates are reviewed, validated, documented, and completed per procedures; maintain backup coverage for continuity.
• Monitor KPIs, quality metrics, and SLA adherence within BPM delivery model.
• Serve as escalation point for complex provider data cases and workflow exceptions.

Skills

Provider data management

Credentialing operations

SLA management

Team leadership

Process governance

Stakeholder communication

Education

Bachelor's degree in Healthcare Administration / related field

Job description

The Provider Data Management (PDM) Team Lead is responsible for end-to-end operational leadership of provider data maintenance services within a Business Process Management (BPM) environment. The role oversees provider outreach verification, returned mail, credentialing record updates, and PIMS claim support while ensuring accurate provider records, inventory control, quality governance, stakeholder communication, process compliance, and adherence to service levels and approved Premera processes and procedures.

Key Responsibilities

Operations Management

• Own daily PDM delivery across outreach verification, returned mail, credentialing record updates, and PIMS claim support.
• Manage work allocation, queue balancing, inventory aging, productivity, and staffing coverage.
• Ensure provider update requests are reviewed, validated, documented, and completed according to approved procedures.
• Maintain backup and replacement coverage to support continuity of service.
• Monitor operational KPIs, productivity, quality metrics, and SLA adherence within the BPM delivery model.

Functional & Escalation Oversight

• Serve as the first point of escalation for complex provider data cases, missing information, provider discrepancies, and workflow exceptions.
• Guide the team on provider demographic, specialty, affiliation, practice location, address, credentialing, and claims-related provider record updates.
• Coordinate provider outreach by email or telephone when verification is required.
• Oversee resolution of PIMS claims where missing group or practitioner data must be loaded to support claims processing.
• Ensure adherence to standardized BPM workflows and operational governance practices.

Quality, Compliance & Governance

• Drive first-time-right processing and adherence to provider data validation controls.
• Lead calibration, defect review, root cause analysis, corrective action, and defect prevention activities.
• Ensure correspondence and supporting evidence are retained for audit readiness.
• Monitor risks involving expirable credentials, returned mail, unresolved verification, and compliance gaps.
• Drive continuous process improvement initiatives to enhance operational efficiency, quality, and customer outcomes.

Stakeholder Management & Reporting

• Partner with Premera operations leads, SMEs, QA, credentialing, claims, compliance, and training teams.
• Prepare weekly operational status reporting covering delivery, inventory, production, issues, risks, decisions, and support required.
• Support monthly service performance reporting, governance reviews, and change control activities.
• Recommend process improvements, documentation updates, and automation opportunities.
• Participate in operational reviews and governance forums to ensure alignment with BPM objectives and service commitments.

People Leadership

• Coach PDM analysts and QA analysts on process knowledge, judgment, documentation, and performance expectations.
• Support new-hire readiness, cross-training, refresher training, and knowledge transfer.
• Promote consistent application of procedures across high-volume provider data workflows.
• Drive employee engagement, capability development, and performance excellence within the BPM operations team.

Mandatory Skills & Competencies

• Strong knowledge of US healthcare payer provider data management and credentialing operations.
• Working knowledge of provider outreach, returned mail, credentialing record maintenance, and PIMS claim workflows.
• Understanding of provider demographics, specialties, affiliations, practice locations, NPI data, licenses, sanctions, and network records.
• Strong inventory management, people leadership, escalation management, and stakeholder communication skills.
• Ability to interpret operational reports, identify risk, and lead corrective actions.
• Strong understanding of BPM operations, SLA management, process governance, quality management, and continuous improvement methodologies.

Qualifications

Education

• Bachelor's degree in Healthcare Administration, Business, Life Sciences, or a related field.

Experience

• 7+ years in US healthcare payer provider data management, credentialing, or provider operations
• Minimum 2+ years in a Team Lead, SME, or supervisory capacity
• Experience working in SLA-driven, high-volume BPM operations