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 across Medicaid, Medicare, and Commercial lines of business. It leads department-specific and cross-departmental planning and execution to maintain performance against enterprise and Provider Network key performance indicators, in alignment with PacificSource’s strategic plan, vision, and values. The Director guides 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. The role leads provider education and relationship management, Credentialing objectives, and the integration and operational effectiveness of provider network platforms. It works with IT, operational leaders, vendors, and other departments to improve interoperability, automate data synchronization, support compliance, and apply LEAN methods. The position participates in strategic planning, resource allocation, performance monitoring, annual IT and initiative work plans, budgeting, and workforce planning. It oversees division leaders and budgets, develops business plans and coaching and training programs, and is responsible for hiring, staff development, performance reviews, and employee engagement. The role also oversees provider collaboration and works across Operations, IT, Health Services, Analytics, Finance, and other functions to align initiatives and improve outcomes for members, provider partners, and PacificSource. The work is performed inside in a general office setting with ergonomically configured equipment. Travel is required approximately 15% of the time. The listed base salary range is $108,468.62–$184,396.64; actual compensation depends on qualifications, experience, education, and internal equity.
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 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.
- Demonstrated collaborative interaction 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 such as 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 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, internal stakeholders, and operational leaders to improve interoperability, identify gaps, and enhance system compatibility.
- Ensure integrated systems support state, federal, and NCQA standards and organizational policies.
- Develop automated workflows that accurately synchronize data across platforms and departments, and guide functionality improvements using LEAN methods and resources.
- Strengthen relationship-management frameworks and ensure 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 people resources support performance and efficiency goals.
- Oversee provider collaborative efforts 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 on network policies, reimbursement processes, and regulatory requirements; assess provider feedback and implement improvements.
- 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 supervisory departments.
- Develop coaching and training programs with division leaders, support team growth, and prioritize resources as new competencies are needed.
- Hire, develop, coach, and evaluate 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 cultural improvements.
- Oversee division budgets and spending, monitor spending against plans, and assess corrective actions as needed.
- Participate in Manager/Supervisor meetings, PRISM walks, internal committees, and other department activities; 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 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
