Director, Provider Network Operations

Job not on LinkedIn

🔥 18 hours ago

🌲 North Carolina – Remote

🌲 North Carolina – 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

• Oversee Provider Network divisions including Provider Relations, Provider Data Management, Credentialing, and provider platform interoperability • Lead strategic initiatives for network setup and maintenance, provider data integrity, provider education and service, contract implementation, provider-related claims, provider setup and audits, corrective action plans, and provider directory accuracy • Develop and execute Credentialing division objectives while 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, internal stakeholders, and operational leaders to improve interoperability and system compatibility • Ensure integrated systems support state, federal, NCQA, and organizational requirements • Develop automated workflows and data-synchronization processes 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 on processes, technology, staffing resources, performance metrics, and efficiency targets • Oversee provider collaborative efforts with other departments and leaders • Guide functional leaders in developing 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, financial budgets, and resource needs • Develop coaching and training programs with division leaders • Oversee hiring, staff development, coaching, and performance reviews for direct reports • Enhance employee engagement within Provider Network • Oversee division budgets and spending and take corrective action as needed • Participate in manager/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 • Follow privacy and HIPAA requirements and perform other assigned duties

🎯 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 • 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 • 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 • 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 • Compliance with PacificSource privacy policy and HIPAA laws and regulations • Ability to stoop and bend, sit and/or stand for extended periods, perform repetitive typing/sorting/filing motions, and lightly lift and carry files and business materials

🏖️ Benefits

• Work-from-home arrangement indicated by location field (WFH: NC) • Travel required approximately 15% of the time • Equal opportunity employment • Employee engagement, education, and cultural enhancement programs • Coaching and training programs • Paid? Not specified • At-will employment