Director, Provider Network Operations

PacificSource•Portland, OR

20d

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 strong performance against enterprise and Provider Network key performance indicators, in alignment with the company’s strategic plan, vision, and values. The position directs network operations, provider education and relationship management, credentialing, provider data integrity, contract implementation, provider-related claims, provider setup and audits, corrective action plans, and provider directory accuracy. It leads integration and operational effectiveness of provider network platforms, develops automated cross-platform data workflows, and works with vendors, IT, and operational stakeholders to improve interoperability and compliance. The Director also oversees strategic planning, budgets, resource allocation, team development, hiring, performance management, and employee engagement. The work is performed in a general office setting with ergonomically configured equipment, and 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 work experience.
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 organizational structure and build high-performing teams.
Proven collaborative interaction experience with provider leaders.
Competencies include authenticity, building organizational talent, coaching and developing others, compelling communication, customer focus, empowerment/delegation, emotional intelligence, leading change, managing conflict, operational decision-making, and passion for results.
Skills in accountable leadership, business and financial acumen, empowerment, influential communications, situational leadership, and strategic planning.
Ability to read and comprehend written and spoken English and communicate clearly and effectively.
Ability to travel approximately 15% of the time.
Physical capacity 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.

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 Credentialing division efforts, ensuring compliance and operational excellence.
Develop and execute provider education and relationship-management strategies to enhance provider collaboration, engagement, and satisfaction.
Lead initiatives to integrate provider network platforms with legacy and emerging systems and ensure their ongoing operational effectiveness.
Build partnerships 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 for accurate synchronization of data across platforms and departments.
Improve functionality through deployment of LEAN methodologies and resources.
Strengthen relationship-management frameworks for 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 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 benefit members, provider partners, and PacificSource.
Design and deliver provider education programs covering network policies, reimbursement processes, and regulatory requirements.
Assess provider feedback and implement enhancements to address pain points and improve relationships.
Partner 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.
Oversee resource planning and prioritization as new competencies are needed when the company grows or expands into new markets.
Hire, develop, coach, and evaluate staff; provide 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 spending against plans, and take corrective action as needed.
Participate in Manager/Supervisor meetings, PRISM walks, internal committees, and other department activities, and disseminate 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 for confidentiality and security of protected health information.
Perform other duties as assigned.