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.

Veterans, Reservists, Guardsmen and military family members are encouraged to apply!

Job Summary

The Provider Certification Specialist is responsible for reviewing, processing, and maintaining certifications for new participating TRICARE network providers in accordance with established TRICARE requirements, timelines, and quality standards. This role conducts certification activities, including primary source verifications, reviews documentation for completeness and accuracy, and communicates with providers to obtain missing or additional information needed to complete the certification process.The Provider Certification Specialist is also responsible for ensuring applicable TRICARE providers are accurately and timely loaded into the provider data system to support operational readiness and downstream business processes, while performing ongoing maintenance of provider certifications and provider data, including updates, changes, and terminations, to support continued regulatory compliance, data integrity, and efficient downstream provider operations. Provider certification is a defined subset of the provider credentialing function and operates within the same Credentialing Department under established service-level, accuracy, and production targets.

Education & Experience

Required:

• High School Diploma or GED
• Minimum of one (1) year of experience in provider credentialing or provider certifications within a managed care, health plan, or healthcare operations environment
• If supporting a TRICARE contract, must be a U.S. Citizen
• If supporting a TRICARE contract, must be able to receive a favorable interim and adjudicated final Department of Defense (DoD) background investigation

Preferred:

• 2+ years of experience in provider credentialing or provider certifications within a managed care, health plan, or healthcare operations environment
• Experience utilizing provider credentialing applications and/or provider data management (PDM) systems Knowledge of URAC and/or NCQA standards
• VA and/or TRICARE program experience

Key Responsibilities

• Review, process, and maintain certification application packets for new participating TRICARE network providers in accordance with established TRICARE requirements, policies, timelines, and quality standards.
• Conduct certification activities, including primary source verifications, criminal history/background and sanctions screenings, and review of supporting documentation for completeness, accuracy, and compliance.
• Communicate with providers and internal stakeholders to obtain missing, incomplete, or additional documentation necessary to complete the certification process within established turnaround times.
• Accurately enter, update, and maintain provider certification and demographic information within credentialing and PDM systems, ensuring applicable TRICARE providers are loaded timely and accurately to support operational readiness and downstream business functions.
• Perform ongoing maintenance of provider certifications and provider data, including updates, changes, revalidations, and terminations; review provider records to identify and resolve discrepancies, data integrity issues, and incomplete information.
• Maintain accurate documentation and electronic records in accordance with organizational policies, regulatory requirements, and audit readiness standards.
• Support regulatory audits, reporting requests, and quality review activities related to provider certification and provider data management processes.
• Ensure adherence to established service level agreements (SLAs), productivity standards, and quality expectations while managing assigned certification activities and work queues.
• Maintain working knowledge of TRICARE requirements, credentialing standards, provider data policies, and applicable regulatory guidelines to ensure ongoing compliance.
• Coordinate with internal departments and work with Credentialing Verification Organization(s) as directed for provider database-related issues.
• Performs other duties as assigned.
• Regular and reliable attendance is required.

Competencies

Commitment to Task: Demonstrates a strong commitment to quality and accountability by adhering to established policies, procedures, timelines, and quality standards while maintaining a high level of motivation, accuracy, and reliability in completing assigned responsibilities.

Communication / People Skills: Demonstrates effective communication and interpersonal skills with the ability to collaborate professionally with providers, internal stakeholders, and cross-functional teams, adapt communication styles to varying situations, actively listen, and facilitate resolution of issues in a professional and customer-focused manner.

Computer Literacy: Ability to effectively work within a multi-system environment using Microsoft applications, including Word, Excel, Outlook, Teams, and SharePoint, as well as department-specific software applications, credentialing systems, intranet resources, and internet-based tools.

Organizational Skills: Detail-oriented with strong organizational skills and the ability to manage multiple tasks and priorities, adapt to changing business needs, learn new systems and processes, and complete work accurately within established timelines and available resources.

Problem Solving / Analysis: Demonstrates strong problem-solving and analytical skills with the ability to systematically evaluate processes, identify discrepancies or incomplete information, apply sound judgment, and resolve issues to support accurate provider certification, data integrity, and compliance with TRICARE requirements.

Technical Skills: Proficient in the use of credentialing software applications and PDM systems, with working knowledge of provider certification and credentialing processes, provider data management practices, and applicable healthcare or managed care operations. Proficient with Microsoft applications, including Outlook, Teams, Word, Excel, and SharePoint. Practical understanding of URAC standards, TRICARE requirements and regulations, and medical terminology.

Working Conditions

Working Conditions:

• Availability to cover any work shift as needed
• May work within a standard office environment
• Extensive time utilizing a computer with prolonged sitting
• Minimal travel is required
• Must be able to obtain appropriate security clearance

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 $46, 000 - $49, 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.