Director of Provider Network

Quantum Recruiters Inc; Oregon; On-site; USD 180,000 - 230,000; Full time

Job summary

Quantum Recruiters Inc in Oregon seeks a senior leader to oversee Provider Network Operations, including Provider Relations, Credentialing, and Data Management. The role directs cross-functional teams, aligns with regulatory requirements, and drives performance across Medicaid, Medicare, and Commercial lines.

The successful candidate will guide strategic initiatives, manage large teams, and optimize interoperability with legacy and emerging systems, fostering strong partnerships with vendors and

Qualifications

• Minimum of 8 years in a leadership role overseeing healthcare provider network operations or related functions.
• Experience leading at least two areas: Provider Relations, Credentialing, and Provider Data Management.
• 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.

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 partner sand PacificSource.
• Strengthen relationship management frameworks to ensure consistent communication and support for provider partners.
• 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.

Skills

Provider Network Leadership

Provider Relations

Credentialing

Provider Data Management

Interoperability

LEAN methodologies

Regulatory compliance

Education

Bachelor’s degree in business, health care administration, finance, or related field

Associate’s degree with experience or high school diploma with experience

Tools

Provider network platforms

Job description

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 forall 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 work flows 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 partner sand PacificSource.
• Strengthen relationship management frameworks to ensure consistent communication and support for provider partners.
• 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.

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.