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, and leads department-specific and cross-departmental planning and execution to maintain performance against enterprise and Provider Network key performance indicators. The role supports all lines of business—Medicaid, Medicare, and Commercial—and aligns work with PacificSource’s strategic plan, vision, and values. The Director leads provider network strategy and operations, including network setup and maintenance, provider data integrity, provider education and service, contract implementation, provider-related claims, audits, corrective action plans, and directory accuracy. The role partners with internal teams and external software vendors to improve provider-platform interoperability, system integration, automated workflows, and operational effectiveness while supporting compliance with state, federal, NCQA, and organizational requirements. The Director works with executive leadership and departments across the organization to plan and monitor performance, initiatives, budgets, technology, staffing, and resources. Responsibilities also include developing provider education and relationship-management programs, leading and developing division leaders and staff, hiring and performance management, employee engagement, and oversight of division budgets and spending. The position is based in a general office setting 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.
- 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 years of 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.
- Demonstrated collaborative interaction with provider leaders.
- 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 plans, and provider directory accuracy.
- Collaborate with the Provider Reimbursement Insights and Analytics Team to meet objectives.
- Direct efforts to meet Credentialing division objectives while ensuring compliance and operational excellence.
- Develop and execute provider education and relationship-management strategies to strengthen provider collaboration, engagement, and satisfaction.
- Lead integration and operational effectiveness of provider network platforms with legacy and emerging systems, working with software vendors and internal stakeholders.
- Collaborate with IT teams and operational leaders to identify interoperability gaps and develop solutions.
- Ensure integrated systems support applicable state, federal, NCQA, and organizational requirements.
- Develop automated workflows and data-synchronization processes, and guide improvements using 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 appropriate processes, technology, and staffing.
- 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 and maximize the value of initiatives.
- Oversee annual IT and initiative work plans, financial budgets, and resource planning for supervisory departments.
- Develop coaching and training programs with division leaders and oversee resource prioritization as the company grows and enters new markets.
- Hire, develop, coach, and review staff; provide feedback through regular one-on-one meetings and performance evaluations for direct reports.
- Enhance employee engagement across 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 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
