Director, Provider Network Operations

Role Description

This position is accountable for the Provider Network department’s core operational, data, and systems functions. This role will oversee Provider Network divisions including Provider Relations, Provider Data Management, Credentialing, and provider platform interoperability. This position leads both department-specific and cross-departmental planning and execution efforts, to maintain high levels of performance in enterprise level and Provider Network level key performance indicators. This position is responsible for all lines of business (Medicaid, Medicare, Commercial) and leads in strong alignment with the company’s strategic plan, vision, and values.

• Guide strategic initiatives for the Provider Network Operations division, including network setup and maintenance, provider data integrity, provider education and service, contract implementation performance, provider-related claims, provider setup and audits, corrective action plan assessment and closure, and provider directory accuracy improvements.
• Collaborate with Provider Reimbursement Insights and Analytics Team to ensure success in meeting objectives. Develop, direct and execute efforts to meet Credentialing division objectives, ensuring compliance and operational excellence.
• Develop and execute strategies for provider education and relationship management to enhance provider collaboration, engagement, and satisfaction within the Provider Relations Team.
• Lead initiatives to ensure seamless integration and ongoing operational effectiveness of provider network platforms with legacy and emerging systems.
• Foster partnerships with software vendors and internal stakeholders to optimize the interoperability of tools and streamline network operations.
• Collaborate with IT teams and operational leaders to identify interoperability gaps and develop solutions to enhance system compatibility.
• Ensure integrated systems support compliance with state, federal, and NCQA standards, as well as organizational policies.
• Develop automated workflows and processes that ensure accurate synchronization of data across all platforms and departments.
• Strengthen relationship management frameworks to ensure consistent communication and support for provider partners.
• Actively participate in department strategic planning, execution, resource allocation, and performance monitoring.
• Oversee and guide provider collaborative efforts in coordination with other key departments and leaders.
• Guide division functional leaders to develop business plans that ensure successful initiatives have a positive impact on the member, provider partners and PacificSource.
• Design and deliver provider education programs to ensure understanding of network policies, reimbursement processes, and regulatory requirements.
• Regularly assess provider feedback and implement enhancements to address pain points and improve relationships.
• In partnership with Operations, IT, Health Services, Analytics, Finance and other departments, collaborate to maximize the alignment and value of various initiatives.
• Oversee the planning of annual IT work plans, initiative work plans, financial budgets, and resource needs for the role of supervisory departments.
• Develop and implement coaching and training programs with division leaders to foster team growth.
• Responsible for hiring, staff development, coaching, and performance reviews.
• Responsible for overall employee engagement enhancement within Provider Network.
• Oversee division budgets and spending. Monitor spending versus the planned budget throughout the year and assess appropriate corrective actions as needed.
• Actively participate in Manager/Supervisor meetings, PRISM walks, internal committees and other key department activities and disseminate information as appropriate.

Qualifications

• Minimum of 8 years in healthcare operations required.
• Management experience required.
• Expertise in provider reimbursement methodologies, provider relations, data management and compliance.
• Experience developing, communicating, and executing strategy in a matrixed organizational structure.
• Bachelor’s degree in business, health care administration, finance, or related field required.
• Candidates with an associate’s degree and 2 years of relevant experience, or a high school diploma and 4 years of relevant experience will also be considered.

Requirements

• Ability to develop and execute strategy.
• Advanced knowledge of provider reimbursement and reimbursement methodologies.
• Ability to lead people in a matrixed organization structure and build high performing teams.
• Proven collaborative interaction experience with provider leaders.

Benefits

• Base Range: $108,468.62 - $184,396.64

Company Description

We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:

• We are committed to doing the right thing.
• We are one team working toward a common goal.
• We are each responsible for customer service.
• We practice open communication at all levels of the company to foster individual, team and company growth.
• We actively participate in efforts to improve our many communities-internally and externally.
• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
• We encourage creativity, innovation, and the pursuit of excellence.