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 Director leads department-specific and cross-departmental planning and execution to maintain performance against enterprise and Provider Network key performance indicators. The role covers Medicaid, Medicare, and Commercial lines of business and aligns with the company’s strategic plan, vision, and values. The Director develops and executes strategies for provider network operations, provider education and relationship management, credentialing, systems interoperability, data synchronization, and operational improvement. The role collaborates with executive leadership and teams across Operations, IT, Health Services, Analytics, Finance, and other departments. It also oversees division plans, budgets, staffing, and resources, while hiring, coaching, developing, and evaluating employees and promoting employee engagement. The work environment is 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; 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 organizational structure and build high-performing teams.
- Proven experience collaborating with provider leaders.
- Ability to read and comprehend written and spoken English and communicate clearly and effectively.
- Physical 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 weighing up to a light amount.
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.
- Relevant experience as described in the alternative education pathways.
Responsibilities
- Guide strategic initiatives covering 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 provider collaboration, engagement, and satisfaction.
- Lead integration and ongoing operational effectiveness of provider network platforms with legacy and emerging systems; work with vendors and internal stakeholders to improve interoperability and streamline operations.
- Work 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 data synchronization across platforms and departments, and improve functionality 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 people resources support performance and efficiency goals.
- Oversee provider collaborative efforts 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 on 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 planning of 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 allocation and prioritization as new competencies are needed.
- Hire, develop, coach, and review 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 spending against budget, 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 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
