Director, Provider Network Operations

This is a fully remote position, open to applicants in Florida.

📋 Description

• Manage the divisions within the Provider Network, including Provider Relations, Provider Data Management, Credentialing, and the interoperability of provider platforms.

• Spearhead planning and execution both within departments and across departments to uphold enterprise and Provider Network performance metrics.

• Direct strategic initiatives related to network establishment and maintenance, provider data accuracy, provider education and service, contract execution, claims related to providers, provider setup and audits, corrective action plans, and the correctness of directories.

• Work in collaboration with Provider Reimbursement Insights and Analytics to achieve set objectives.

• Oversee the efforts of the Credentialing division to meet objectives, ensure compliance, and achieve operational excellence.

• Create strategies for provider education and relationship management.

• Lead the integration and operational efficiency of provider network platforms with both legacy and emerging systems.

• Collaborate with software vendors, IT teams, operational leaders, and internal stakeholders to enhance interoperability and improve operational workflows.

• Ensure that integrated systems adhere to state, federal, NCQA, and organizational standards.

• Develop automated workflows to ensure accurate data synchronization across platforms and departments.

• Enhance functionality utilizing LEAN methodologies and available resources.

• Engage in strategic planning, execution, resource allocation, and performance monitoring.

• Partner with executive leadership on processes, technology, human resources, performance metrics, and efficiency objectives.

• Supervise collaborative efforts among providers and other departments and leaders.

• Assist functional leaders in formulating business plans.

• Create and deliver provider education programs covering network policies, reimbursement processes, and regulatory obligations.

• Evaluate provider feedback and implement enhancements to relationships.

• Collaborate with Operations, IT, Health Services, Analytics, Finance, and additional departments.

• Oversee annual IT work plans, initiative work plans, financial budgets, and resource requirements.

• Develop coaching and training initiatives in partnership with division leaders.

• Manage resource prioritization and the development of new competencies.

• Recruit, develop, coach, and evaluate staff members.

• Conduct one-on-one meetings and performance assessments for direct reports.

• Boost employee engagement through educational programs and cultural initiatives.

• Manage division budgets and expenditures, taking corrective actions as necessary.

• Participate in manager/supervisor meetings, PRISM walks, internal committees, and departmental activities.

• Evaluate innovative provider payment methodologies for approval and implementation.

• Perform other assigned duties.

⛳️ Requirements

• A minimum of 8 years of experience in a leadership position overseeing healthcare provider network operations or related functions is required.

• Experience leading at least two areas among Provider Relations, Credentialing, and Provider Data Management is strongly preferred.

• Proven experience in managing large, multi-tier teams and complex operational portfolios.

• Required knowledge of provider reimbursement methodologies, provider network operations, compliance necessities, and healthcare data management.

• Preferred experience in developing and executing strategy within a matrixed organization.

• A Bachelor’s degree in business, healthcare administration, finance, or a related field is required.

• Candidates with an associate’s degree and 2 years of relevant experience, or a high school diploma and 4 years of relevant experience, in addition to the required minimum years of work experience will also be considered.

• Ability to develop and execute effective strategies.

• Advanced knowledge of provider reimbursement and reimbursement methodologies, provider relations, or provider partnership activities in relevant markets and regions.

• Capability to lead individuals within a matrixed organizational structure and to build high-performing teams.

• Documented experience in collaborative interactions with provider leaders.

• Work within a general office setting equipped with ergonomically configured equipment.

• Travel is needed approximately 15% of the time.

• Meet department and company performance standards and attendance expectations.

• Adhere to PacificSource privacy policy and HIPAA laws and regulations regarding confidentiality and security of protected health information.

• Ability to read and understand both written and spoken English.

• Communicate effectively and clearly.

• Capable of stooping and bending; sitting and/or standing for extended periods; performing repetitive typing, sorting, and filing; and light lifting and carrying.

🏝️ Benefits

• Flexible telecommuting policy.

• Medical, vision, and dental insurance.

• Incentive program.

• Paid time off and holidays.

• 401(k) plan.

• Opportunities for volunteering.

• Tuition reimbursement and training.

• Life insurance.

• Flexible spending account.

• Opportunities for personal growth and advancement.

• Learning, development, and career advancement opportunities.

• Work-life balance.

• Training and individual development opportunities.