Director, Provider Relations and Medical Networks

Encova•Charleston, WV

7h•Remote

About The Position

Encova Insurance is seeking a Director of Provider Relations and Medical Networks. This can be a home-based role open to candidates residing anywhere within our payroll footprint, as detailed on our careers page. Occasional travel may be required for meetings or projects. The position will report directly to the Vice President of Claims Product and Operations. Are you a Referral? If you know a current Encova Insurance associate and would like to apply as a referral, please encourage them to submit your referral information before you submit your application. You will receive an email with a direct URL link to the Job Posting of interest. Applying through this URL link will create your referral relationship for our Talent Acquisition Team. Unique residence requirements are listed in each job posting, please review closely for details. Encova is only able to employ associates who reside and work within specific U.S. states. Our current policies are based on the laws in states in which we are registered for payroll. Our current footprint includes: Connecticut, Delaware, Florida, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Nebraska, New Hampshire, New Jersey, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, West Virginia, Wisconsin. JOB OBJECTIVE: The Director, Provider Relations and Medical Networks leads a technical team and is responsible for developing and executing strategies to manage and reduce medical expenses within the workers’ compensation program. This role ensures compliance with regulatory requirements, oversees vendor relationships, and implements best practices to deliver quality care while controlling costs.

Requirements

Bachelor’s degree or equivalent in healthcare administration, business, or related field is required.
Minimum of 7 years of insurance experience in workers’ compensation or medical cost containment is required.
Strong knowledge of provider networks, fee schedules, utilization review, and pharmacy management.
Excellent communication, negotiation, analytical, and leadership skills.

Nice To Haves

Previous experience in a leadership or management role is strongly desired.
Demonstrated experience with managed care programs and vendor management is preferred.
Familiarity with state workers’ compensation regulations and cost strategies is strongly preferred.
Ability to lead cross-functional teams and drive measurable results.

Responsibilities

Provide leadership through coaching, mentoring and directing the medical network, provider relations and medical bill review teams providing them with development opportunities as appropriate.
Develop and implement medical cost containment strategies aligned with organizational goals.
Monitor industry trends and regulatory changes to ensure compliance and optimize performance.
Manage provider networks, utilization review, bill review, and pharmacy benefit programs.
Oversee negotiations with medical providers and vendors to ensure competitive pricing and quality outcomes.
Analyze medical cost drivers and identify opportunities for savings.
Prepare reports and present findings to senior leadership with actionable recommendations.
Work closely with claims teams, nurse case managers, and legal to ensure integrated cost containment efforts.
Serve as a subject matter expert for medical cost containment strategies and regulatory compliance.
Other duties as assigned.