Director, Network Operations

About Us ' Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women ' Children's Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR ' Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions. ' Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more. Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve. Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers. Job Summary The Director, Network Operations provides strategic and operational leadership for Community provider network operations, provider data integrity, regulatory reporting, provider communications, and related network-support functions. The Director is accountable for establishing the operating model, governance standards, performance measures, and cross-functional practices needed to maintain accurate provider information, timely and reliable regulatory submissions, effective provider communications, and consistent support of Community's provider network. This position translates Network Management priorities into department strategies, annual objectives, performance expectations, and sustainable processes. The Director leads the interpretation and resolution of complex provider data, reporting, system, workflow, and compliance issues; oversees audit and regulatory readiness; and partners with Provider Contracting, Provider Engagement, Credentialing, Claims, Compliance, Information Technology, Quality, and other stakeholders to strengthen data quality, operational effectiveness, provider experience, and organizational decision-making. JOB SPECIFICATIONS AND CORE COMPETENCIES Network Operations Strategy, Governance, and Performance Develop and execute the provider network operations strategy in alignment with Network Management and organizational priorities. Establish department goals, operating standards, governance practices, service expectations, performance measures, and escalation protocols. Provide strategic oversight of provider data integrity, regulatory reporting, provider communications, network coordination, and related operational support activities. Evaluate operational risks, capacity, workflow dependencies, and performance trends; determine corrective actions and resource priorities. Present network operations performance, risks, trends, and recommendations to the VP, Network Management and other leaders. Provider Data Integrity, Reporting, and Regulatory Oversight Direct governance and quality oversight for provider data used in claims, directories, regulatory submissions, network reporting, and operational decision-making. Ensure processes support accurate, complete, timely, and auditable state and federal reporting, including applicable Texas HHSC and CMS requirements. Establish validation, reconciliation, quality review, issue management, and corrective-action standards for provider data and regulatory reporting. Oversee investigation and resolution of complex data discrepancies, reporting exceptions, root-cause issues, and recurring operational defects. Maintain readiness for audits, regulatory inquiries, accreditation reviews, and internal quality assessments related to network operations. People Leadership and Department Management Lead, coach, and develop assigned network operations employees and establish clear accountability for quality, timeliness, service, and results. Set work priorities, allocate resources, monitor performance, and maintain appropriate coverage across provider data, communications, coordination, and reporting functions. Oversee recruitment, onboarding, training, performance management, succession planning, and employee development in partnership with Human Resources. Build a collaborative, accountable, and continuous-improvement culture that supports consistent execution and knowledge continuity. Ensure employees understand applicable policies, procedures, regulatory expectations, and internal control requirements. Cross-Functional Partnership, Systems, and Process Improvement Partner with Provider Contracting, Provider Engagement, Credentialing, Claims, Compliance, Quality, Information Technology, Finance, and other teams to resolve network operational issues and improve end-to-end processes. Sponsor and lead approved process, reporting, automation, and system-improvement initiatives that strengthen accuracy, efficiency, scalability, transparency, and provider service. Define business requirements, support testing and implementation, and monitor adoption and outcomes for network operations tools and system changes. Establish communication and issue-resolution practices that ensure stakeholders receive accurate information, clear ownership, and timely follow-through. Identify enterprise-level trends and recommend policy, workflow, data-governance, or technology changes to Network Management leadership. Other Duties And Departmental Contributions Perform other duties as assigned and contribute to departmental goals, annual business plans, and approved organizational initiatives. Qualifications Education/Specialized Training/Licensure: Bachelor's degree in Business Administration, Healthcare Administration, Public Health, Health Information Management, Data Analytics, or a related field from an accredited college or university required. Master's degree in Healthcare Administration, Business Administration, Public Health, Informatics, or a related field preferred. Work Experience (Years and Area): Ten (10) or more years of progressively responsible experience in managed care, health plan operations, provider network operations, provider data, regulatory reporting, healthcare analytics, or a closely related function, including at least five (5) years in provider network operations, provider data governance, regulatory reporting, or healthcare analytics Experience with Texas Medicaid, CHIP, STAR+PLUS, Marketplace, Medicare, or other government-sponsored health programs Management Experience (Years and Area): Five (5) or more years of formal people-leadership experience, including accountability for performance management, employee development, work allocation, operational results, and cross-functional execution. Director-level or multi-function leadership experience in a managed care or regulated healthcare environment. Software Proficiencies: Advanced proficiency with Microsoft 365, including Excel, PowerPoint, Word, Outlook, and Teams; experience with provider data, claims, reporting, workflow, or business-intelligence systems. Experience with SQL, Power BI, Salesforce, QNXT, provider directory platforms, data-quality tools, or comparable systems. Other: Demonstrated knowledge of provider network operations, provider data integrity, regulatory reporting, audit readiness, process governance, performance measurement, and cross-functional issue resolution. Strong executive communication, analytical, decision-making, change-leadership, and relationship-management skills. Ability to manage competing priorities and lead complex initiatives in a regulated environment. Knowledge of NCQA, URAC, Texas HHSC, CMS, provider directory, network adequacy, and delegated oversight requirements. Relevant healthcare, project management, analytics, or process-improvement certification. #J-18808-Ljbffr