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. The role oversees Provider Relations, Provider Data Management, Credentialing, and provider platform interoperability, and leads department-specific and cross-departmental planning and execution to maintain strong performance against enterprise and Provider Network key performance indicators. It serves all lines of business—Medicaid, Medicare, and Commercial—and aligns work with PacificSource’s strategic plan, vision, and values. The Director guides 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. The role leads Credentialing objectives, provider relationship and education strategies, and initiatives to integrate provider network platforms with legacy and emerging systems. It collaborates with IT, operational leaders, and other departments to close interoperability gaps, improve system compatibility, support compliance, and develop automated data synchronization and LEAN processes. The position participates in strategic planning, resource allocation, performance monitoring, annual IT and initiative work plans, budgets, and staffing plans. It guides division leaders in developing business plans and oversees provider collaborative efforts. It is responsible for hiring, staff development, coaching, performance reviews, employee engagement, and division budgets and spending. The role also supports provider payment methodology assessment, department activities, privacy and HIPAA compliance, and other assigned duties. The work is performed inside in 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.
- 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, 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.
- 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 meet the physical requirements of stooping and bending; sitting and/or standing for extended periods; repetitive typing, sorting, and filing; and light lifting and carrying of 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 and objectives, ensuring 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, working with software vendors and internal stakeholders to optimize interoperability and streamline 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 data synchronization across platforms and departments, and guide functionality improvements using 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 staffing support performance and efficiency targets.
- Oversee provider collaborative efforts in coordination 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 about 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 maximize alignment and value of initiatives.
- Oversee annual IT work plans, initiative work plans, financial budgets, and resource needs for supervised 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 review staff; provide feedback through regular one-on-one meetings and performance evaluations for direct reports.
- Enhance employee engagement within Provider Network through education, programs, and other cultural initiatives.
- 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 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
