Director, Provider Network Operations

PacificSource•Boise, ID

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 departmental and cross-functional planning and execution to maintain performance against enterprise and Provider Network key performance indicators, aligned 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, 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, automate accurate data synchronization, support compliance, and streamline operations. It also guides provider relationship management, education, credentialing, collaborative initiatives, and continuous improvement efforts using LEAN methodologies. The position oversees division leaders, staffing, employee engagement, training, performance management, budgets, annual IT and initiative work plans, and resource allocation. It partners with executive leadership and teams across Operations, IT, Health Services, Analytics, Finance, and other departments to deliver initiatives that benefit members, providers, and PacificSource. The work is performed in a general office setting with ergonomically configured equipment, and 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 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 collaborative interaction experience 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 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 provider education and relationship-management strategies to improve provider collaboration, engagement, and satisfaction.
Lead initiatives to integrate provider network platforms with legacy and emerging systems and maintain their operational effectiveness.
Partner with software vendors, IT teams, operational leaders, and internal stakeholders to identify interoperability gaps and improve system compatibility.
Ensure integrated systems support state, federal, and NCQA standards and organizational policies.
Develop automated workflows that ensure accurate data synchronization across platforms and departments.
Improve functionality through deployment of LEAN methodologies and resources.
Strengthen provider relationship-management frameworks and 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 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, providers, and PacificSource.
Design and deliver provider education programs on 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 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 regular feedback, one-on-one meetings, and performance evaluations for direct reports.
Enhance employee engagement within Provider Network through education, programs, and cultural improvements.
Oversee division budgets and spending, monitor spending against plans, and take corrective action as appropriate.
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 requirements for confidentiality and security of protected health information.
Perform other duties as assigned.