Description

We offer remote work opportunities (AK, AR, AZ, CO, FL, HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, WA, WI & WY only).

Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.

Veteran, Military Spouse or Military Affiliated are encouraged to apply!

Job Summary

The Provider Credentialing Representative is responsible for overseeing complex certification and credentialing activities, with a focus on tracking and reporting escalations to ensure timely resolution. This role facilitates meetings to discuss and resolve certification and credentialing issues and concerns, manages the Credentialing shared inbox to provide accurate and prompt responses to internal and external inquiries, and collaborates closely with Credentialing department leaders to evaluate and refine processes. The Provider Credentialing Representative plays a key role in driving operational efficiency, ensuring that performance metrics and production goals are consistently achieved while maintaining compliance with regulatory requirements and accreditation standards.

Education & Experience

Required:

• 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

Preferred:

• 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

Key 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.

Competencies

Communication / People Skills: Effectively influences and persuades others in both favorable and challenging situations to achieve desired outcomes. Adapts communication and interaction style to effectively connect with diverse individuals and audiences. Listens attentively and critically to ensure understanding and informed responses, as well as to facilitate clear communication and effective collaboration. Communicates clearly and concisely in both written and verbal formats.

Computer Literacy: Proficient in navigating multiple systems, including Microsoft applications, department-specific tools, and organization-wide platforms, to perform tasks.

Coping / Flexibility: Maintains resilience when adapting to diverse situations and stakeholders, sustaining focus and applying a professional, solution-oriented approach to problem solving.

Empathy / Customer Service: Consistently demonstrates customer-focused behaviors that anticipate needs and support a positive service experience. Exhibits a helpful and service-oriented approach, characterized by active listening, patience, respect, and genuine empathy for others' perspectives.

Independent Thinking / Self-Initiative: Applies critical thinking to independently prioritize the issues and activities that most directly drive desired outcomes. Demonstrates a strong sense of ownership by advancing work independently, securing required resources, and driving tasks to completion without the need for direction.

Information Management: Ability to analyze large volumes of data, derive sound conclusions, and concisely and clearly communicate insights to diverse stakeholders.

Organizational Skills: Demonstrates exceptional attention to detail and the ability to effectively prioritize, coordinate, and manage multiple tasks or stakeholders. Adapts to shifting priorities and deadlines while efficiently utilizing available systems and resources to achieve timely, accurate outcomes.

Problem Solving / Analysis: Ability to resolve issues by applying systematic process analysis and exercising sound, informed judgment. Maintains a realistic and accurate understanding of relevant issues when evaluating problems and determining solutions.

Technical Skills: Practical understanding of URAC standards, VA CCN and TRICARE regulations and requirements, as well as medical terminology. Current and applied knowledge of primary source verifications for initial credentialing, re-credentialing, and provider certifications. Current and applied knowledge of delegated credentialing processes Proficient with credentialing software and provider data management systems. Proficient with Microsoft applications (Outlook, Teams, Word, Excel, PowerPoint, and SharePoint) and other tools.

Working Conditions

Working Conditions:

• Availability to cover any work shift as needed
• Travel may be required
• May work within a standard office environment
• Extensive time utilizing a computer with prolonged sitting

Company Overview

Taking Care of Our Nation's Heroes.

It's Who We Are. It's What We Do.

Do you have a passion for serving those who served?

Join the TriWest Healthcare Alliance Team! We're On a Mission to Serve®!

Our job is to make sure that America's heroes get connected to health care in the community.

At TriWest Healthcare Alliance, we've proudly been on that important mission since 1996.

DoD Statement

Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.

Benefits

We're more than just a health care company. We're passionate about serving others! We believe in rewarding loyal, hard-working people who are willing to learn as they grow. TriWest Healthcare Alliance values teamwork. Join our team, fulfill your responsibilities, and you may also be considered for frequent pay raises, overtime opportunities to earn even more, recognition and reward programs, and much more. Of course, we also offer a comprehensive and progressive compensation and benefits package that includes:

• 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

TriWest job postings typically include a salary range, which can vary based on the specific role and location, but generally this position ranges from around $49,000 to $52,000 per year.

Equal Employment Opportunity

TriWest Healthcare Alliance is an equal employment opportunity employer. We are proud to have an inclusive work environment and know that a diverse team is a strength that will drive our success. To that end, TriWest strives to create an inclusive environment that supports diversity at every organizational level, and we highly encourage candidates from all backgrounds to apply. Applicants are considered for positions based on merit and without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability or any other consideration made unlawful by applicable federal, state, or local laws.