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-department planning and execution to maintain strong performance against enterprise and Provider Network key performance indicators. The role is responsible for Medicaid, Medicare, and Commercial lines of business and aligns its work with PacificSource’s strategic plan, vision, and values. The Director guides strategic initiatives across 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 leads Credentialing objectives, provider education and relationship management, and the integration and ongoing operation of provider network platforms. It works with internal teams and software vendors to address interoperability gaps, support compliant integrated systems, and automate accurate data synchronization. The position participates in strategic planning, execution, resource allocation, and performance monitoring; oversees annual IT and initiative work plans, budgets, and resource needs; and partners with executive leadership and departments such as Operations, IT, Health Services, Analytics, and Finance. It guides division leaders in developing business plans, oversees provider collaborative efforts, and works to improve provider communication, support, education, and satisfaction. The Director is responsible for hiring, staff development, coaching, performance reviews, employee engagement, and division budgets and spending. The role also assesses provider payment methodologies, meets department and company performance and attendance expectations, follows privacy and HIPAA requirements, and performs other duties as assigned. 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 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 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.
- Ability to meet department and company performance and attendance expectations.
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 Provider Network Operations strategic initiatives, 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.
- Collaborate with the Provider Reimbursement Insights and Analytics Team to meet objectives.
- Develop, direct, and execute efforts to meet Credentialing division objectives, compliance requirements, and operational standards.
- Develop and execute provider education and relationship-management strategies to enhance collaboration, engagement, and satisfaction.
- Lead integration and ongoing operational effectiveness of provider network platforms with legacy and emerging systems.
- Partner with software vendors, IT teams, operational leaders, and internal stakeholders to improve interoperability, system compatibility, and network operations.
- Ensure integrated systems support state, federal, and NCQA standards and organizational policies.
- Develop automated workflows to synchronize data accurately across platforms and departments, and improve functionality using LEAN methodologies and resources.
- Strengthen provider relationship-management frameworks and ensure consistent provider communication and support.
- Participate in department strategic planning, execution, resource allocation, and performance monitoring, and work with executive leadership to ensure resources and processes 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 on 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 across 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, and oversee resource prioritization as new competencies are needed.
- Hire, develop, coach, and evaluate staff, including providing regular feedback and one-on-one meetings to direct reports.
- Enhance employee engagement within Provider Network through education, programs, and 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 key 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 policies and HIPAA laws and regulations 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
