Director, Provider Network Operations

PacificSource•Springfield, OR

20d

About The Position

The Director, Provider Network Operations is accountable for the Provider Network department’s core operational, data, and systems functions across Medicaid, Medicare, and Commercial lines of business. The role oversees Provider Relations, Provider Data Management, Credentialing, and provider platform interoperability, leading department-specific and cross-department planning and execution to maintain strong performance against enterprise and Provider Network key performance indicators. The Director aligns work with the company’s strategic plan, vision, and values. The position leads strategic initiatives involving 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. It also guides Credentialing objectives, provider relationship management, and integration of provider network platforms with legacy and emerging systems. The Director collaborates with executive leadership, IT, Operations, Health Services, Analytics, Finance, vendors, and other stakeholders to support compliance, interoperability, efficient workflows, and successful initiatives. The Director oversees division leaders, budgets, staffing, resource allocation, employee development, engagement, and performance management. The position is based in a general office setting with ergonomically configured equipment and requires approximately 15% travel.

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 meet the physical requirements of stooping and bending; sitting and/or standing for extended periods; repetitive typing, sorting, and filing; light lifting and carrying of files and business materials; reading and comprehending written and spoken English; and communicating 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 plan assessment and closure, and provider directory accuracy improvements.
Collaborate with the Provider Reimbursement Insights and Analytics Team to meet objectives.
Develop, direct, and execute Credentialing division efforts and ensure compliance and operational excellence.
Develop and execute provider education and relationship-management strategies to enhance 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 and internal stakeholders to optimize interoperability and streamline network 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 to synchronize data accurately across platforms and departments.
Improve functionality through LEAN methodologies and resources.
Strengthen relationship-management frameworks and support consistent communication with provider partners.
Participate in department strategic planning, execution, resource allocation, and performance monitoring.
Work with executive leadership to ensure processes, technology, and people resources 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, 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 maximize initiative alignment and value.
Oversee annual IT and 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 into new markets.
Hire, develop, coach, and conduct performance reviews for staff; provide 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 take corrective action 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 protected health information.
Perform other duties as assigned.