Director, Provider Network Operations

🔥 0 minutes ago

🌲 North Carolina – Remote

🌲 North Carolina – Remote

💵 $108.5k - $184.4k / year

⏰ Full Time

🔴 Lead

🌐 Network Operations

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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

• Guide strategic initiatives for Provider Network Operations, including 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 • Collaborate with the Provider Reimbursement Insights and Analytics Team to meet objectives • Develop, direct, and execute Credentialing division objectives while ensuring compliance and operational excellence • Develop and execute provider education and relationship-management strategies • Lead integration and ongoing operational effectiveness of provider network platforms with legacy and emerging systems • Partner with software vendors and internal stakeholders to optimize tool interoperability and streamline network operations • Collaborate with IT teams and operational leaders to identify interoperability gaps and develop solutions • Ensure integrated systems support state, federal, and NCQA standards and organizational policies • Develop automated workflows and processes for accurate data synchronization 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 with other departments and leaders • Guide functional leaders in developing business plans • Design and deliver provider education programs on 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 and implement coaching and training programs with division leaders • Oversee resources and prioritization as new competencies are needed • Hire, develop, coach, and conduct performance reviews for staff • Provide feedback, regular one-on-one meetings, and performance evaluations for direct reports • Enhance employee engagement within Provider Network through education, programs, and cultural initiatives • Oversee division budgets and spending; monitor budget variance and corrective actions • Participate in Manager/Supervisor meetings, PRISM walks, internal committees, and department activities • Assess new 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 required • 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 required • 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 • Ability to read and comprehend both written and spoken English • Communicate clearly and effectively • Travel required approximately 15% of the time • Ability to stoop and bend • Ability to sit and/or stand for extended periods while performing core job functions • Repetitive motions including typing, sorting, and filing • Light lifting and carrying of files and business materials • Must follow privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information

🏖️ Benefits

• Flexible telecommute policy • Medical, vision, and dental insurance • Incentive program • Paid time off and holidays • 401(k) plan • Volunteer opportunities • Tuition reimbursement and training • Life insurance • Flexible spending account option • Opportunities for personal growth and advancement • Learning, development, and career advancement opportunities • Work-life balance • Individual development and career advancement support