Principal, Provider Data Management

Location: Hybrid 3 days (offices in NYC, Denver, CO and Charlotte, NC area)

Position Summary:

The Principal, Provider Data Management is the enterprise subject-matter expert and senior steward for provider, network, roster, and provider contract data. This role ensures provider data is accurate, governed, compliant, and consistently propagated to claims, repricing, directories, portals, analytics, care navigation, vendors, and client-facing reporting. The Principal owns standards and controls for provider adds, deletes, terminations, demographic changes, network participation, contract attributes, effective dates, fee schedule references, product/tier applicability, and roster reconciliation.

This position operates at a senior individual-contributor level: leading governance design, resolving complex data issues, strengthening claims-pricing defensibility, mentoring operational teams, and driving sustainable improvements across provider data intake, maintenance, quality, audit readiness, and downstream consumption.

Position Responsibilities:

• Lead enterprise provider-data governance for critical provider and contract fields, including NPI, TIN, taxonomy/specialty, locations, group/facility relationships, network status, effective/termination dates, product applicability, and contract references.
• Own compliant processes for provider adds, deletes, changes, and terminations, including source documentation, approval controls, effective-date logic, exception handling, audit trail, and SLA oversight.
• Manage and improve roster operations for contracted groups, facilities, ancillaries, direct contracts, COEs, high-performance networks, wrap networks, and other network arrangements.
• Partner with Network Contracting, Product and Engineering teams and Third-Party vendors to translate contract terms, amendments, carve-outs, fee schedules, tiers, and reimbursement indicators into accurate provider data and pricing setup requirements.
• Ensure accurate downstream propagation to claims, repricing, provider directories, member/provider portals, eligibility, care navigation, UM, analytics, stop-loss, client reporting, EDI/data feeds, and external vendors.
• Design and run data-quality controls: completeness checks, duplicate detection, roster reconciliation, effective-date validation, contract-data alignment, exception reporting, and root-cause correction plans.
• Serve as escalation point for high-impact issues involving claims pricing, network assignment, directory accuracy, access-to-care, provider payment, client implementation, or compliance exposure.
• Maintain SOPs, data dictionaries, governance rules, change-control artifacts, intake templates, QA checklists, reconciliation standards, and management reporting.
• Support audits, regulatory readiness, network adequacy/directory accuracy needs, NSA/balance-billing operations, and client commitments by producing defensible documentation and control evidence.
• Mentor analysts/specialists, influence cross-functional operating practices, and lead continuous-improvement initiatives that increase data quality, speed, transparency, and accountability.

Required Qualifications:

• Bachelor’s degree in healthcare administration, business, information systems, analytics, or a related field
• 7+ years of healthcare provider data, network operations, payer/TPA operations, claims configuration, provider relations, or healthcare data-governance experience.
• Data stewardship, contract-data fluency, claims/network acumen, governance mindset, executive communication, root-cause problem solving, cross-functional leadership.
• Advanced understanding of provider identifiers, provider hierarchies, roster management, contract data, network participation, effective dating, and downstream payer/TPA system impacts.
• Demonstrated ability to govern provider adds/deletes/changes with strong controls, documentation, reconciliation, audit readiness, and issue-resolution discipline.
• Strong knowledge of how provider data impacts claims pricing, repricing, member liability, provider directories, network access, client implementations, reporting, and vendor integrations.
• Advanced Excel/data-analysis skills and comfort working with large datasets, exception reports, data feeds, workflow tools, and operational dashboards.
• Ability to influence senior stakeholders across Network Contracting, Claims, IT, EDI/Data Engineering, Compliance, Legal, Provider Relations, Analytics, Client Implementation, and vendors.

Preferred Qualifications:

• Experience in a medical TPA, PPO/network vendor, self-funded employer/ASO, captive, direct-contracting, repricing, or health plan environment.
• Experience with contract loading, fee schedules, claims-pricing logic, tiered networks, COEs, direct primary care, wrap networks, value-based arrangements, or provider directory/network adequacy processes.
• Working knowledge of SQL, data warehouses, EDI/file feeds, provider master data tools, claims platforms, CRM/workflow platforms, or data visualization/reporting tools.
• Experience building governance frameworks, data dictionaries, operating metrics, QA controls, and audit-ready documentation for provider/network data.
• Relevant training/certification in healthcare operations, data governance, project management, Lean/Six Sigma, compliance, or analytics.