Director, Provider Credentialing and Data Governance

Role Snapshot

The Director, Provider Credentialing & Data Governance oversees three highly interdependent pillars:
Commercial credentialing/re-credentialing programs, a matrixed delegated credentialing audit framework, and maintaining public-facing provider directory integrity. This role is accountable to architect the transition and maintenance of legacy data structures into a next‑generation provider data platform. The Director directly impacts the Health Plan's financial accuracy, market expansions, and regulatory compliance by ensuring seamless provider data flow from initial onboarding through claims adjudication.

140-160k, pay may flucuate based on experience.

• This position will be hybrid, having the regional availability to come into our office 2 days a week. Our office location: WPS Corporate Center Building - 1717 W. Broadway in Madison, WI, 53713

• Establish enterprise standards and data governance to ensure a single, trusted source of provider information.
• Define and manage processes supporting provider configuration, demographic maintenance, and complex contract setup within core systems.
• Oversee vendor data management to maintain quality, compliance, and alignment with organizational goals.
• Manage and evaluate vendor performance and coordinate with leaders to identify risks, develop mitigation plans, and communicate status to senior leadership.
• Establish and maintain performance standards and quality measures that support ongoing provider directory accuracy and ensure provider directories meet all state and federal regulatory requirements across digital and print channels.
• Advance master data management practices and strengthen enterprise data governance related to provider information.
• Manage credentialing and recredentialing arrangements, contractual obligations, audits and corrective actions to maintain compliance with URAC/NCQA, CMS and all regulatory requirements.
• Serve as Chair for the internal Credentialing Committee, steering agenda design, high‑risk case escalations, and Peer Review workflows.
• Maintain credentialing data integrity and reporting, monitor key performance metrics and turnaround times.
• Manages vendors relationships that assist with key business processes and workflows.
• Evaluate and implement vendor technologies to improve data, directory accuracy, and/or network adequacy monitoring. Oversees system upgrades, enhancements, and ongoing software updates.
• Lead, mentor, and develop staff to foster a culture of accountability, excellence, and engagement.
• Support division training to ensure consistent application of policies, guidelines, and regulatory requirements.
• Other job-related duties may be assigned as assigned.

• Bachelor's degree in healthcare administration, business management or a related field or equivalent combination of education and experience.
• Ten (10) or more years of health plan work experience with 5 or more years in direct related work and leadership experience in provider relations, network development functions and/or credentialing.
• In depth understanding of relevant healthcare federal and state regulations and requirements.
• Exceptional leadership and team‑building capabilities.
• Excellent interpersonal and communication skills with the ability to influence and build relationships across various stakeholders.
• Strong critical thinking and analytical skills.
• Demonstrated experience identifying, prioritizing and driving work efforts with the highest returns on investment to achieve desired health plan goals.
• Ability to work in a complex, rapidly evolving and deadline‑driven environment with multiple internal and external stakeholders.