Director, Provider Network Operations

Job not on LinkedIn

🔥 20 hours ago

🐊 Florida – Remote

🐊 Florida – Remote

💵 $108.5k - $184.4k / year

⏰ Full Time

🔴 Lead

🌐 Network Operations

👻 Ghost score 0%

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PacificSource Health Plans

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1933

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

PacificSource Health Plans is a healthcare provider that offers a range of health insurance solutions, including plans for individuals, families, and employers. Their offerings include Medicare and Medicaid plans, dental coverage, and administrative services for small and large groups. Committed to member care, PacificSource emphasizes customer service and provides various resources for health management, including mental health support and wellness programs.

📋 Description

• Lead Provider Network Operations across Provider Relations, Provider Data Management, Credentialing, and provider platform interoperability • Guide strategic initiatives for network setup and maintenance, provider data integrity, provider education, contract implementation, provider-related claims, audits, corrective action plans, and directory accuracy • Collaborate with reimbursement insights and analytics teams to meet objectives • Develop and execute Credentialing division objectives, ensuring compliance and operational excellence • Develop provider education and relationship management strategies to improve provider collaboration, engagement, and satisfaction • Lead integration and operational effectiveness of provider network platforms with legacy and emerging systems • Partner with software vendors, IT teams, and internal stakeholders to optimize interoperability and streamline operations • Identify interoperability gaps and develop solutions to enhance system compatibility • Ensure systems comply with state, federal, NCQA, and organizational standards • Develop automated workflows and synchronize data across platforms and departments • Improve functionality through LEAN methodologies and resources • Participate in strategic planning, execution, resource allocation, and performance monitoring • Work with executive leadership to align processes, technology, and people resources with performance and efficiency targets • Oversee provider collaborative efforts and division business plans • Design and deliver provider education programs covering network policies, reimbursement processes, and regulatory requirements • Assess provider feedback and implement relationship improvements • Collaborate with Operations, IT, Health Services, Analytics, Finance, and other departments • Oversee annual IT work plans, initiative work plans, budgets, and resource needs for supervisory departments • Develop coaching and training programs with division leaders • Oversee hiring, staff development, coaching, performance reviews, and employee engagement • Manage division budgets, spending, and corrective actions • Participate in manager and supervisor meetings, PRISM walks, internal committees, and department activities • Assess innovative provider payment methodologies for approval and implementation • Meet department and company performance and attendance expectations • Perform other duties as assigned

🎯 Requirements

• Minimum of 8 years of experience in a leadership role overseeing healthcare provider network operations or related functions • Experience leading at least two of Provider Relations, Credentialing, and Provider Data Management strongly preferred • 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 • Experience developing and executing strategy within a matrixed organization preferred • 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 • Advanced knowledge of provider reimbursement and reimbursement methodologies, provider relations, or provider partnership activities • Ability to lead people in a matrixed organization structure and build high performing teams • Proven collaborative interaction experience with provider leaders • Accountable leadership, business and financial acumen, empowerment, influential communications, situational leadership, and strategic planning • Ability to read and comprehend both written and spoken English • Ability to communicate clearly and effectively • Ability to stoop and bend, sit and/or stand for extended periods, perform repetitive motions, and lift/carry files and business materials • Travel required approximately 15% of the time • Must follow PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information

🏖️ Benefits

• Equal opportunity employer committed to diversity, equity, inclusion, and social justice • Employee engagement programs and cultural enhancements • Coaching and training programs • Professional development and staff development opportunities