Director, Provider Network Operations
About The Position
The Director, Provider Network Operations is accountable for the Provider Network department’s core operational, data, and systems functions. The role oversees Provider Relations, Provider Data Management, Credentialing, and provider platform interoperability across Medicaid, Medicare, and Commercial lines of business. It leads department-specific and cross-departmental planning and execution to maintain performance against enterprise and department key performance indicators, in alignment with PacificSource’s strategic plan, vision, and values. The Director guides strategy and operations for provider 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 position drives credentialing objectives, provider relationship management, platform interoperability, compliance, process automation, and continuous improvement. It partners with executive leadership and departments including Operations, IT, Health Services, Analytics, and Finance on planning, resources, budgets, and operational priorities. The role manages division leaders and staff, including hiring, development, coaching, performance reviews, employee engagement, and resource prioritization. It also oversees division budgets and spending, provider collaborative efforts, training and education programs, and performance monitoring. The position works in a general office setting with ergonomically configured equipment and requires approximately 15% travel.
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; alternatively, an associate’s degree plus 2 years of relevant experience, or a high school diploma plus 4 years of relevant experience, in addition to the required minimum 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 and build high-performing teams.
- Demonstrated collaborative interaction with provider leaders.
- Accountable leadership, business and financial acumen, empowerment, influential communications, situational leadership, and strategic planning skills.
- Ability to read and comprehend written and spoken English and communicate clearly and effectively.
- Ability to stoop and bend; sit and/or stand for extended periods; perform repetitive typing, sorting, and filing; and lift and carry files and business materials.
Nice To Haves
- Experience leading at least two of 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 plans, and provider directory accuracy.
- 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 collaboration, engagement, and satisfaction.
- Lead the integration and ongoing operational effectiveness of provider network platforms with legacy and emerging systems; partner with software vendors and internal stakeholders to improve interoperability and streamline operations.
- Work with IT teams and operational leaders to identify interoperability gaps and develop solutions that improve system compatibility.
- Ensure integrated systems support state, federal, and NCQA standards and organizational policies.
- Develop automated workflows and processes for accurate data synchronization across platforms and departments, and guide functionality improvements using LEAN methodologies and resources.
- Strengthen relationship-management frameworks to provide consistent communication and support to provider partners.
- Participate in strategic planning, execution, resource allocation, and performance monitoring; work with executive leadership to ensure processes, technology, and personnel 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 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 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 for company growth and expansion.
- Hire, develop, coach, and evaluate staff; provide regular feedback, 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 take corrective action as needed.
- Participate in Manager/Supervisor meetings, PRISM walks, internal committees, and other department activities, and share information as appropriate.
- Assess innovative provider payment methodologies for approval and implementation.
- Meet department and company performance and attendance expectations.
- Follow PacificSource privacy policy and HIPAA requirements concerning protected health information.
- Perform other duties as assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Director
