Director, Provider Network Operations

PacificSource•Bend, 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 PacificSource’s strategic plan, vision, and values. The director guides provider network operations, including 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 role also leads credentialing objectives, provider relationship strategies, and interoperability efforts involving internal teams, vendors, and legacy and emerging systems. It ensures systems and processes support applicable regulatory and organizational requirements, and promotes improved functionality through LEAN methodologies and automated workflows. The position works with executive leadership and partners across Operations, IT, Health Services, Analytics, Finance, and other departments to plan and deliver initiatives, budgets, work plans, and resource needs. It leads division leaders and teams through business planning, hiring, coaching, training, performance management, and employee engagement efforts. The role is based in a general office setting with ergonomically configured equipment, and requires travel 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, 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 organization and build high-performing teams.
Demonstrated collaborative interaction 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.
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.

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 plans, and provider directory accuracy.
Collaborate with the Provider Reimbursement Insights and Analytics Team to meet objectives.
Develop, direct, and execute Credentialing division efforts to meet 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 for seamless integration and ongoing operational effectiveness of provider network platforms with legacy and emerging systems.
Partner with software vendors and internal stakeholders to optimize interoperability and streamline network 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 to synchronize data accurately across platforms and departments.
Improve functionality through LEAN methodologies and resources.
Strengthen provider relationship-management frameworks and 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 metrics and efficiency and stewardship targets.
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 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 and 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 for company growth and expansion 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 other 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 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 protected health information.
Perform other duties as assigned.