Note: The job is a remote job and is open to candidates in USA. TriWest Healthcare Alliance is dedicated to connecting America's heroes with healthcare services. The Provider Credentialing Representative oversees certification and credentialing activities, ensuring compliance with regulatory requirements while driving operational efficiency and addressing any escalations that arise.
Responsibilities
• Ensures credentialing and certification activities adhere to regulatory requirements, accreditation criteria, federal program guidelines, and internal quality standards
• Leads the review and evaluation of certification and credentialing processes to identify gaps, redundancies, and improvement opportunities; recommend and support implementation of process enhancements aligned with organizational policies and accreditation standards
• Serves as an internal resource and subject-matter expert on credentialing policies, workflows, systems, and best practices; provides guidance to team members and cross-functional partners as needed
• Manages the credentialing shared inbox, ensuring triage, prioritization, and resolution of incoming requests, inquiries, and escalations within established service-level expectations
• Monitors, tracks, and reports on certification and credentialing escalations to ensure timely, accurate, and compliant resolution; initiates follow-up actions and coordinates cross-functional support as needed
• Facilitates and coordinates meetings with internal departments and external stakeholders to address certification and credentialing issues, concerns, or process dependencies; documents outcomes and drives execution of agreed-upon action items
• Supports the development, review, and ongoing maintenance of provider communication materials, including notices, guides, templates, and FAQs, to ensure accuracy, clarity, and alignment with current certification and credentialing requirements and organizational expectations
• Assists in developing, compiling, and distributing routine and ad hoc reports on certification and credentialing metrics, KPIs, backlog trends, workflow timeliness, and quality indicators; contributes to presenting findings to leadership and recommending improvement strategies
• Collaborates with internal teams to validate system updates, contributes to process documentation, and assists in readiness efforts for audits or accreditation reviews
• Participates in or leads special projects, workflow assessments, and operational initiatives focused on enhancing credentialing efficiency, provider experience, and organizational compliance
• Regular and reliable attendance at work
• Performs other duties as assigned
Skills
• High School Diploma or GED
• 2+ years of provider credentialing experience
• 2+ years of experience working with credentialing applications and provider data management systems to support end-to-end credentialing and data workflows
• Working knowledge of URAC and/or NCQA standards, as well as VA, TRICARE, or other federal program requirements
• If supporting TRICARE contract, must be a U.S. Citizen
• If supporting TRICARE contract, must be able to receive a favorable interim and adjudicated final Department of Defense (DoD) background investigation
• 3+ years of provider credentialing experience
• 3+ years of experience working with credentialing applications and provider data management systems to support end-to-end credentialing and data workflows
Benefits
• Medical, Dental and Vision Coverage
• Paid time off
• 401(k) Retirement Savings Plan (with matching)
• Short-term and long-term disability, basic life, and accidental death and dismemberment insurance
• Tuition reimbursement
• Paid volunteer time
Company Overview
• TriWest Healthcare Alliance - Serving Those Who Serve. At TriWest, we honor the sacrifice and service of our nations military families by It was founded in 1996, and is headquartered in Phoenix, Arizona, USA, with a workforce of 1001-5000 employees. Its website is http://triwest.com.
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