Director, Provider Network Operations
About The Position
This position is accountable for the Provider Network department’s core operational, data, and systems functions. It oversees Provider Relations, Provider Data Management, Credentialing, and provider platform interoperability. The role leads department-specific and cross-departmental planning and execution to maintain performance against enterprise and Provider Network key performance indicators. It covers Medicaid, Medicare, and Commercial lines of business and aligns with PacificSource’s strategic plan, vision, and values. The Director guides strategic initiatives, oversees operational and compliance performance, strengthens provider relationships and education, and leads integration of provider network platforms with legacy and emerging systems. The role works closely with internal departments, executive leadership, technology teams, and software vendors to improve operational effectiveness, data synchronization, and system interoperability. The position also oversees staffing, employee development and engagement, budgets, financial and IT work plans, and resource allocation across supervisory departments. The work is performed inside in a general office setting with ergonomically configured equipment. Travel is required approximately 15% of the time.
Requirements
- At least 8 years of experience in a leadership role overseeing healthcare provider network operations or related functions.
- 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, may also be considered in addition to the required minimum years of work experience.
- Advanced knowledge of provider reimbursement and reimbursement methodologies, provider relations, or provider partnership activities in relevant markets and geography.
- Ability to develop and execute strategy.
- Ability to lead people in a matrixed organization structure and build high-performing teams.
- Proven collaborative interaction experience with provider leaders.
- Accountable leadership, business and financial acumen, empowerment, influential communications, situational leadership, and strategic planning skills.
- Ability to stoop and bend; sit and/or stand for extended periods; perform repetitive motions such as typing, sorting, and filing; and lift and carry files and business materials lightly.
- 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 enhance collaboration, engagement, and satisfaction.
- Lead initiatives to integrate provider network platforms with legacy and emerging systems and maintain their operational effectiveness.
- Partner with software vendors and internal stakeholders to optimize interoperability and streamline network operations.
- Collaborate with IT teams and operational leaders to identify interoperability gaps and develop system compatibility solutions.
- Ensure integrated systems support state, federal, and NCQA standards and organizational policies.
- Develop automated workflows and processes to synchronize data accurately across platforms and departments.
- Guide functionality improvements using LEAN methodologies and resources.
- Strengthen relationship-management frameworks to provide consistent communication and support for 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 performance and efficiency targets.
- Oversee provider collaborative efforts 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 about network policies, reimbursement processes, and regulatory requirements.
- Assess provider feedback and implement enhancements to address pain points and improve relationships.
- Collaborate with Operations, IT, Health Services, Analytics, Finance, and other departments to align initiatives and maximize their value.
- Oversee annual IT work plans, initiative work plans, financial budgets, and resource needs for supervisory departments.
- Develop and implement coaching and training programs with division leaders and oversee resource prioritization as new competencies are needed.
- Hire, develop, coach, and evaluate staff, including providing regular feedback and one-on-one meetings to direct reports.
- Enhance employee engagement within 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 department activities, and disseminate 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 the 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
