Director, Provider Operations

Job Description

Job Description

Description:

POSITION SUMMARY

The Director of Provider Operations is the operational owner of the provider experience across Blue Zones Health’s medical groups, delegated MSO, and RBO and IPA networks. The role carries two core accountabilities: 1) running the network smoothly by reactively and proactively eliminating the operational friction that burdens providers and disrupts patient care; and 2) representing the network as a standing operational voice internally at BZH and externally to health plans to shape policies and practices.

WHY THIS ROLE EXISTS

In a delegated managed care environment, the provider experience succeeds or fails at the operational level, i.e., whether claims adjudicate correctly, authorizations process on time, referrals handoffs complete, provider data is accurate, and contracts translate into what providers receive. When these break down, providers absorb the cost in administrative burden, delayed reimbursement and disrupted patient care.

This Director was created to own it: resolution of issues end-to-end, educating and communicating with providers, maintaining the integrity of provider data and contracts, and representing the BZH network with a prepared, consistent voice so that policies and practices reflect the network’s operational reality.

CORE RESPONSIBILITIES

Provider Issue Resolution & Escalation Management

• Own end-to-end resolution of provider escalations across claims, referrals, and authorizations from intake through close, with accountability for provider communication and SLAs by issue type
• Serve as escalation authority for issues that cross functional lines, engaging claims, medical management, network teams, or health plan operational contacts as needed. Maintain ownership of the issue regardless of where the resolution occurs
• Convert escalation patterns into systemic improvements, using trend data to drive internal process improvement and to bring documented network-level issues to health plan governance channels

Provider Education and Communication

• Own the provider communication strategy, defining approach, cadence and channel mix for proactive outreach and reactive communication
• Translate operational and clinical complexity into clear, actionable, provider-facing content, including training materials, reference guides, and targeted education requiring provider behavior change
• Measure effectiveness of communication and education

Provider Data and Contract Management

• Maintain provider data accuracy across delegated systems, payer rosters, and provider directories
• Ensure provider enrollment and onboarding timelines align with contracting and billing activation
• Implement executed contracts, ensure accurate representation in system configuration; execute contract amendments

Health Plan Relationship Management & Network Representation

• Maintain a current roster of health plan operational contacts; serve as central internal coordination point for health plan operational inquiries and accuracy
• Serve as central internal contact for health plan operational inquiries, ensuring accuracy and consistency
• Develop and maintain BZH network’s operational position on health plan practices; provide structured and fact-based artifacts in health plan forums. Represent BZH network voice and advocate/influence for improvements
• Support delegation audits and reporting cadences

Process Design & Continuous Improvement

• Lead cross-functional workgroups to optimize operational workflows across the MSOs and RBO/IPAs; identify failure points and redesign for efficiency and compliance with NCQA, CMS, state regulators, and delegation requirements
• Develop and maintain SOPs and training materials for Provider Operations; drive adoption of operational tools including provider portals
• Create and implement provider KPIs and dashboards; measure and meet provider experience metrics. Conduct quarterly operational reviews with key provider groups and implement improvement roadmaps

Compliance

• Comply with all applicable federal, state, and local laws, as well as all Employer policies, procedures, and standards, including but not limited to codes of conduct and ethics requirements, as amended from time to time.

Required

• Bachelor's degree in Healthcare Administration, Business, Nursing, or related field
• 7+ years of progressive experience in healthcare operations, provider relations, managed care, or health plan/MSO/RBO/IPA administration
• Demonstrated experience working across claims, utilization management, and provider-facing functions simultaneously
• In-depth knowledge of medical claims processing, prior authorization workflows, and referral management in a managed care or delegated environment
• Experience with RBO, IPA, MSO, and/or delegated model operations, including payer delegation requirements and oversight
• Strong command of HIPAA, CMS, and applicable state regulatory requirements (e.g., DMHC, DIFS) governing provider operations and compliance
• Proven ability to lead cross-functional teams and manage competing priorities in a fast-paced environment
• Advanced proficiency with claims platforms (e.g., EZ-CAP, TriZetto, QNXT, Availity) and electronic health record/care management systems

Preferred

• Master's degree (MHA, MBA, MPH) or equivalent advanced experience
• Experience with NCQA accreditation and HEDIS measure management in a delegated environment
• Lean, Six Sigma, or equivalent process improvement certification
• Coding or billing background (CPC, CPMA, or equivalent) a plus
• Bilingual capabilities aligned with the patient/provider population served