Director, Provider Network Operations

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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.

Essential Responsibilities

• 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. Fostering 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. Guiding efforts to improve functionality via the deployment of LEAN methodologies and resources.
• 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. Work with executive leadership to ensure processes, technology, and people resources are in place to achieve success in both key performance metrics and efficiency/stewardship targets.
• 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. Oversee resources and prioritization of those resources as new competencies are needed when the company grows and expands into new markets.
• Responsible for hiring, staff development, coaching, and performance reviews. Provide feedback, including regular one-on-one meetings and performance evaluations for direct reports.
• Responsible for overall employee engagement enhancement within Provider Network to include implementation of education/programs and other desired cultural enhancements.
• 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.

Supporting Responsibilities

• Assess new and innovative provider payment methodologies for approval and implementation.
• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.

Success Profile

• Work Experience: Minimum of 8 years of experience in a leadership role overseeing healthcare provider network operations or related functions required.
• Experience leading at least two of the following areas is strongly preferred: Provider Relations, Credentialing, and Provider Data Management.
• Demonstrated experience managing large, multi-level teams and complex operational portfolios.

Knowledge of provider reimbursement methodologies, provider network operations, compliance requirements, and healthcare data management required. Experience developing and executing strategy within a matrixed organization preferred.

Education, Certificates, Licenses: 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, in addition to the required minimum years of work experience will also be considered.

Knowledge: Ability to develop and execute strategy Advanced knowledge of provider reimbursement and reimbursement methodologies, provider relations, or provider partnership activities in relevant markets and geography. Ability to lead people in a matrixed organization structure and build high performing teams. Proven collaborative interaction experience with provider leaders.

• Competencies
• Authenticity
• Building Organizational Talent
• Coaching and Developing Others
• Compelling Communication
• Customer Focus
• Empowerment/Delegation
• Emotional Intelligence
• Leading Change
• Managing Conflict
• Operational Decision Making
• Passion for Results

Additional information

Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 15% of the time.

Skills

Accountable leadership, Business & financial acumen, Empowerment, Influential Communications, Situational Leadership, Strategic Planning

Physical Requirements

• Stoop and bend.
• Sit and/or stand for extended periods of time while performing core job functions.
• Repetitive motions to include typing, sorting and filing.
• Light lifting and carrying of files and business materials.
• Ability to read and comprehend both written and spoken English.
• Communicate clearly and effectively.