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 across Medicaid, Medicare, and Commercial lines of business. The role oversees Provider Relations, Provider Data Management, Credentialing, and provider platform interoperability, and leads department and cross-department planning and execution to support strong performance against enterprise and Provider Network key performance indicators. The director aligns work with PacificSource’s strategic plan, vision, and values. The position leads strategic initiatives involving network setup and maintenance, provider data integrity, education and service, contract implementation, provider-related claims, provider setup and audits, corrective action plans, directory accuracy, credentialing, and provider relationships. It also oversees integration and operational effectiveness of provider network platforms, works with IT and operational leaders to address interoperability gaps, and supports compliance with applicable state, federal, NCQA, and organizational requirements. The director collaborates across Operations, IT, Health Services, Analytics, Finance, and other departments; oversees work plans, budgets, resource allocation, and performance monitoring; and works with executive leadership to ensure people, processes, and technology support business goals. The role leads and develops division leaders and teams, including hiring, coaching, training, performance reviews, employee engagement, and budget oversight. The position is based 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.
- 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 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 organizational structure and build high-performing teams.
- Proven collaborative interaction experience with provider leaders.
- 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.
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 to integrate provider network platforms with legacy and emerging systems and maintain their operational effectiveness.
- Partner with software vendors and internal stakeholders to improve 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 synchronize data accurately across platforms and departments.
- Guide functionality improvements using LEAN methodologies and resources.
- Strengthen relationship-management frameworks to ensure 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 staffing 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 and initiatives 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 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 annual IT and 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 initiatives.
- Oversee division budgets and spending, monitor actual spending against plan, 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 requirements 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
