Director, Provider Network Operations

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

📋 Description

• Responsible for the core operational, data, and systems functions of the Provider Network department.

• Supervise divisions such as Provider Relations, Provider Data Management, Credentialing, and provider platform interoperability.

• Lead both department-specific and cross-departmental planning and execution initiatives.

• Direct strategic initiatives related to network setup and maintenance, provider data integrity, provider education and service, contract implementation, provider-related claims, provider setup and audits, corrective action plans, and the accuracy of provider directories.

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

• Manage the Credentialing division to ensure 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.

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

• Ensure that systems comply with state, federal, NCQA, and organizational requirements.

• Develop automated workflows to ensure accurate data synchronization.

• Enhance functionality through LEAN methodologies and resources.

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

• Collaborate with executive leadership on processes, technology, human resources, performance metrics, and efficiency targets.

• Oversee collaborative provider efforts and guide functional leaders in business planning.

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

• Coordinate initiatives with Operations, IT, Health Services, Analytics, Finance, and other departments.

• Manage annual IT work plans, initiative work plans, financial budgets, and resource needs.

• Develop coaching and training programs in conjunction with division leaders.

• Supervise resource prioritization and the development of new competencies.

• Recruit, develop, coach, and conduct performance reviews for staff members.

• Foster employee engagement within the Provider Network.

• Manage division budgets, track spending, and implement 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 additional duties as assigned.

⛳️ Requirements

• At least 8 years of experience in a leadership position managing healthcare provider network operations or similar functions.

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

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

• Strong understanding of provider reimbursement methodologies, provider network operations, compliance requirements, and healthcare data management.

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

• 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 those with a high school diploma and 4 years of relevant experience, along with the required minimum years of work experience, will also be considered.

• Ability to develop and implement strategic initiatives.

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

• Capability to lead teams in a matrixed organization and foster high-performing teams.

• Proven experience in collaborative interactions with provider leaders.

• Proficient in reading and understanding both written and spoken English.

• Ability to communicate clearly and effectively.

• Must meet departmental and company performance and attendance standards.

• Adhere to PacificSource privacy policies and HIPAA laws and regulations concerning the confidentiality and security of protected health information.

• Ability to stoop and bend.

• Capable of sitting and/or standing for extended periods.

• Able to perform repetitive motions, including typing, sorting, and filing.

• Light lifting and carrying of files and business materials is required.

🏝️ Benefits

• Employment opportunities on an equal basis.

• Opportunities for leadership, coaching, and professional development.

• Programs focused on employee engagement and cultural enhancement.

• A general office environment equipped with ergonomically designed equipment.

• Travel is required approximately 15% of the time.