Director, Provider Network Operations

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

📋 Description

• Lead strategic initiatives for Provider Network Operations, encompassing network establishment and upkeep, provider data integrity, education, service, contract implementation, claims related to providers, provider setup and audits, corrective action plans, and accuracy of provider directories.

• Collaborate with Provider Reimbursement Insights and Analytics to achieve objectives.

• Direct the Credentialing division objectives while ensuring compliance and operational excellence.

• Create strategies for provider education and relationship management.

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

• Partner with software vendors, IT teams, operational leaders, and internal stakeholders to enhance interoperability and system compatibility.

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

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

• Enhance functionality utilizing LEAN methodologies and resources.

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

• Collaborate with executive leadership to align processes, technology, and human resources with performance and efficiency targets.

• Supervise provider collaborative efforts and guide division functional leaders in creating business plans.

• Design and implement provider education programs that address network policies, reimbursement processes, and regulatory requirements.

• Evaluate provider feedback and implement improvements in relationships.

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

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

• Create coaching and training programs in collaboration with division leaders.

• Supervise hiring, staff development, coaching, and performance evaluations for direct reports.

• Foster employee engagement within the Provider Network.

• Manage division budgets and expenditures, implementing corrective measures as necessary.

• Participate in Manager/Supervisor meetings, PRISM walks, internal committees, and departmental activities.

• Evaluate innovative provider payment methodologies for approval and execution.

• Perform additional duties as assigned.

⛳️ Requirements

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

• Strong preference for experience leading at least two of the following areas: Provider Relations, Credentialing, and Provider Data Management.

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

• Comprehensive knowledge of provider reimbursement methodologies, provider network operations, compliance requirements, and healthcare data management.

• Experience in developing and executing strategy within a matrixed organization is preferred.

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

• An Associate’s degree coupled with 2 years of relevant experience, or a high school diploma with 4 years of relevant experience, in addition to the required minimum years of work experience will also be taken into account.

• Capability 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 teams within a matrixed organization and build high-performing teams.

• Proven experience in collaborative interactions with provider leaders.

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

• Ability to communicate clearly and effectively.

• Ability to stoop and bend, sit and/or stand for extended periods, perform repetitive typing/sorting/filing motions, and lift and carry files and business materials.

• Must meet department and company performance and attendance standards.

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

🏝️ Benefits

• Work from home designation (WFH: NC).

• Equal opportunity employment.

• Employee engagement and cultural enhancement programs.

• Coaching and training programs.

• Travel opportunities/requirements approximately 15% of the time.