Director, Provider Network Operations

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

📋 Description

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

• Direct strategic initiatives related to network establishment and maintenance, ensuring provider data accuracy, provider education and support, contract implementation, claims processing related to providers, audits, corrective action plans, and the accuracy of provider directories.

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

• Create, guide, and implement objectives for the Credentialing division to ensure compliance and operational excellence.

• Formulate and execute strategies for provider education and relationship management.

• Lead the integration and continual 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 system compatibility.

• Ensure that integrated systems comply with state, federal, and NCQA standards, as well as organizational policies.

• Develop automated workflows and enhance functionality utilizing LEAN methodologies.

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

• Collaborate with executive leadership to align processes, technology, and personnel resources with performance and efficiency benchmarks.

• Supervise collaborative efforts among providers and oversee division business plans.

• Design and implement provider education programs while addressing provider feedback.

• Work alongside Operations, IT, Health Services, Analytics, Finance, and other departments.

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

• Develop coaching and training initiatives with division leaders.

• Recruit, train, mentor, and conduct performance evaluations for staff and direct reports.

• Foster employee engagement within the Provider Network.

• Manage division budgets and expenditures, and implement corrective measures 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 areas.

• Strongly preferred experience leading at least two of the following: Provider Relations, Credentialing, and Provider Data Management.

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

• Familiarity with provider reimbursement methodologies, provider network operations, compliance requirements, 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, alongside the required minimum years of work experience, will also be considered.

• Ability to formulate and execute strategy effectively.

• Advanced knowledge of provider reimbursement and reimbursement methodologies, provider relations, or provider partnership activities relevant to the markets and geography.

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

• Demonstrated collaborative interaction experience with provider leaders.

• Strong leadership accountability, business and financial acumen, empowerment, influential communication skills, situational leadership, and strategic planning capabilities.

• Proficiency in reading and comprehending both written and spoken English.

• Ability to communicate clearly and effectively.

• Physical ability to stoop and bend, sit and/or stand for long periods, perform repetitive tasks, and lift and carry files and business materials.

• Must meet departmental and company performance and attendance standards.

• Must adhere to PacificSource privacy policies and HIPAA laws and regulations regarding confidentiality and security of protected health information.

🏝️ Benefits

• Full-time employment.

• Work-from-home arrangement.

• Equal opportunity employment.

• Employee engagement, education, and cultural enhancement programs.

• Coaching and training programs.

• Approximately 15% travel.