Director, Provider Network Operations

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

📋 Description

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

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

• Direct both department-specific and cross-departmental planning and execution to uphold enterprise and Provider Network KPIs.

• Lead strategic initiatives related to network establishment and upkeep, provider data accuracy, provider education and service, contract execution, provider-related claims, provider onboarding and audits, corrective action plans, and the accuracy of provider directories.

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

• Steer Credentialing goals to guarantee compliance and operational excellence.

• Formulate strategies for provider education and relationship management.

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

• Cultivate relationships with software vendors and internal stakeholders to enhance interoperability.

• Collaborate with IT and operational leaders to pinpoint interoperability gaps and devise solutions.

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

• Create automated workflows for precise cross-platform and cross-department data synchronization.

• Enhance functionality using LEAN methodologies and resources.

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

• Partner with executive leadership to synchronize processes, technology, and human resources with performance and efficiency objectives.

• Oversee collaborative efforts of providers with other departments and leaders.

• Assist functional leaders in crafting business plans.

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

• Evaluate provider feedback and introduce improvements in relationships.

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

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

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

• Supervise resource prioritization and the development of new competencies.

• Recruit, develop, mentor, and conduct performance evaluations for staff.

• Provide ongoing feedback and conduct one-on-one meetings with direct reports.

• Enhance employee engagement within the Provider Network.

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

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

• Assess innovative provider payment methodologies for endorsement and implementation.

• Execute additional duties as assigned.

⛳️ Requirements

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

• Experience leading at least two of the following: Provider Relations, Credentialing, and Provider Data Management is strongly preferred.

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

• In-depth knowledge of provider reimbursement methodologies, provider network operations, compliance requirements, and healthcare data management is essential.

• 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.

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

• Capacity to develop and implement strategies.

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

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

• Demonstrated collaborative interaction experience with provider leaders.

• Ability to meet department and company performance and attendance standards.

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

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

• Effective communication skills.

• Ability to stoop and bend.

• Capacity to sit and/or stand for prolonged periods while executing core job functions.

• Capable of repetitive motions including typing, sorting, and filing.

• Ability to perform light lifting and carrying of files and business materials.

🏝️ Benefits

• Equal opportunity employment.

• Occasional travel, approximately 15% of the time.

• Access to coaching and training programs.

• Employee engagement and cultural enhancement initiatives.

• Ergonomically configured equipment.