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 strong performance against enterprise and Provider Network key performance indicators. The role covers Medicaid, Medicare, and Commercial lines of business and aligns its work with the company’s strategic plan, vision, and values. The Director leads strategic initiatives and operational improvements across 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 works with internal teams and software vendors to improve provider platform interoperability, system compatibility, data synchronization, compliance, and operational effectiveness. It also guides provider relationship management, education, and collaboration. The position participates in strategic planning, resource allocation, performance monitoring, annual IT and initiative work plans, budgeting, and operational efficiency efforts. It oversees division leaders and budgets, and is responsible for hiring, staff development, coaching, performance reviews, and employee engagement. The role works with executive leadership and departments including Operations, IT, Health Services, Analytics, and Finance to advance initiatives and support organizational objectives. 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; 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.
- 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 organization and build high-performing teams.
- Proven experience collaborating with provider leaders.
- Skills in accountable leadership, business and financial acumen, empowerment, influential communications, situational leadership, and strategic planning.
- Ability to stoop and bend; sit and/or stand for extended periods; perform repetitive motions including typing, sorting, and filing; and lift and carry files and business materials lightly.
- 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.
- Develop, direct, and execute efforts to meet Credentialing division objectives and ensure compliance and operational excellence.
- Develop and execute strategies for provider education and relationship management to improve collaboration, engagement, and satisfaction.
- Lead initiatives to integrate and maintain effective provider network platforms with legacy and emerging systems, working with vendors and internal stakeholders to improve interoperability and streamline operations.
- Collaborate with IT teams and operational leaders to identify interoperability gaps and develop solutions that improve system compatibility.
- Ensure integrated systems support state, federal, and NCQA standards and organizational policies.
- Develop automated workflows and processes that synchronize data accurately across platforms and departments; guide improvements using LEAN methodologies and resources.
- Strengthen relationship management frameworks for consistent provider communication and support.
- Participate in department strategic planning, execution, resource allocation, and performance monitoring; work with executive leadership to ensure processes, technology, and staffing support performance 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 enhancements to address pain points and improve relationships.
- Collaborate with Operations, IT, Health Services, Analytics, Finance, and other departments to align and maximize the value of initiatives.
- Oversee 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 for company growth and expansion.
- Manage hiring, staff development, coaching, and performance reviews; provide regular feedback and conduct one-on-one meetings and performance evaluations for direct reports.
- Improve employee engagement within Provider Network through education, programs, and cultural enhancements.
- 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 policies and HIPAA laws and regulations regarding 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
