Director, Provider Network Operations
About The Position
This position is accountable for the core operational, data, and systems functions of PacificSource’s Provider Network department. It oversees Provider Relations, Provider Data Management, Credentialing, and provider platform interoperability across Medicaid, Medicare, and Commercial lines of business. The role leads department-specific and cross-departmental planning and execution to maintain strong performance against enterprise and Provider Network key performance indicators, in alignment with the company’s strategic plan, vision, and values. The Director guides network setup and maintenance, provider data integrity, provider education and service, contract implementation, provider-related claims, provider setup and audits, corrective action plans, and provider directory accuracy. The role leads credentialing objectives and compliance, provider relationship and education strategies, and the integration and operational effectiveness of provider platforms and systems. It collaborates with IT and operational leaders to address interoperability gaps, improve data synchronization and workflows, and ensure systems meet applicable standards and policies. The role participates in strategic planning, execution, resource allocation, and performance monitoring; oversees work plans, budgets, and resource needs; and works across departments and with executive leadership to align initiatives. It guides division leaders in developing business plans and oversees hiring, staff development, coaching, performance reviews, employee engagement, budgets, and spending. Travel is required approximately 15% of the time. The work is performed inside in a general office setting with ergonomically configured equipment.
Requirements
- At least 8 years of experience in a leadership role overseeing healthcare provider network operations or related functions.
- Demonstrated experience managing large, multi-level teams and complex operational portfolios.
- Knowledge of provider reimbursement methodologies, provider network operations, compliance requirements, and healthcare data management.
- Bachelor’s degree in business, health care administration, finance, or a related field; candidates with an associate’s degree and 2 years of relevant experience, or a high school diploma and 4 years of relevant experience, in addition to the required minimum years of work experience, will also be considered.
- Ability to develop and execute strategy.
- Advanced knowledge of provider reimbursement and reimbursement methodologies, provider relations, or provider partnership activities in relevant markets and geography.
- Ability to lead people in a matrixed organization structure and build high-performing teams.
- Proven collaborative interaction experience with provider leaders.
- Ability to read and comprehend written and spoken English and communicate clearly and effectively.
Nice To Haves
- Experience leading at least two of the following areas: Provider Relations, Credentialing, and Provider Data Management.
- Experience developing and executing strategy within a matrixed organization.
Responsibilities
- Guide strategic initiatives for Provider Network Operations, including network setup and maintenance, provider data integrity, provider education and service, contract implementation performance, provider-related claims, provider setup and audits, corrective action plan assessment and closure, and provider directory accuracy improvements.
- Collaborate with the Provider Reimbursement Insights and Analytics Team to meet objectives.
- Develop, direct, and execute efforts to meet Credentialing division objectives and ensure compliance and operational excellence.
- Develop and execute provider education and relationship-management strategies to improve provider collaboration, engagement, and satisfaction.
- Lead initiatives for seamless integration and ongoing operational effectiveness of provider network platforms with legacy and emerging systems.
- Partner with software vendors and internal stakeholders to optimize platform interoperability and streamline network operations.
- Collaborate with IT teams and operational leaders to identify interoperability gaps and develop solutions that improve system compatibility.
- Ensure integrated systems support compliance with state, federal, and NCQA standards and organizational policies.
- Develop automated workflows and processes to ensure accurate synchronization of data across platforms and departments.
- Guide functionality improvements through deployment of LEAN methodologies and resources.
- Strengthen relationship-management frameworks to support consistent communication with provider partners.
- Participate in department strategic planning, execution, resource allocation, and performance monitoring.
- Work with executive leadership to ensure processes, technology, and people resources support key performance metrics and efficiency and stewardship targets.
- Oversee provider collaborative efforts in coordination with other departments and leaders.
- Guide division functional leaders in developing business plans that positively affect members, provider partners, and PacificSource.
- Design and deliver provider education programs covering network policies, reimbursement processes, and regulatory requirements.
- Assess provider feedback and implement improvements to address pain points and strengthen relationships.
- Collaborate with Operations, IT, Health Services, Analytics, Finance, and other departments to align and maximize the value of initiatives.
- Oversee planning of annual IT and initiative work plans, financial budgets, and resource needs for supervisory departments.
- Develop and implement coaching and training programs with division leaders to foster team growth.
- Oversee resources and prioritization as new competencies are needed when the company grows and expands into new markets.
- Hire, develop, coach, and review staff; provide feedback through regular one-on-one meetings and performance evaluations for direct reports.
- Enhance employee engagement across Provider Network through education, programs, and cultural improvements.
- Oversee division budgets and spending, monitor actual spending against plans, and assess corrective actions as needed.
- Participate in Manager/Supervisor meetings, PRISM walks, internal committees, and other key department activities, and share information as appropriate.
- Assess new and innovative provider payment methodologies for approval and implementation.
- Meet department and company performance and attendance expectations.
- Follow PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
- Perform other duties as assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Director
