Director – Provider Services, Health Plan

Jobtailor; Albuquerque (NM); Hybrid; USD 120,000 - 170,000; Full time

Job summary

Jobtailor in Albuquerque, NM is seeking a senior leader to oversee provider servicing operations, education, and relationship management across a broad provider network. You will act as the escalation point for complex issues and drive standardized workflows with cross-functional teams.

The role focuses on value-based payment programs, analytical performance reporting, and compliant contracting strategies. You’ll partner with IT and finance to optimize pricing, savings, and population health

Qualifications

• Bachelor's degree or 6 years of additional experience.
• 10+ years in provider relations, contracting, claims, and customer service in a managed care organization.
• Strong understanding of reimbursement methodologies (FFS, capitation, shared savings, risk-based models).
• Excellent communication and public speaking skills.
• Experience with large integrated delivery systems and population health models.

Responsibilities

• Lead provider servicing operations, including issue resolution, education, and relationship management.
• Serve as escalation point for complex provider issues with timely resolution.
• Establish standardized servicing models, workflows, and performance expectations.
• Collaborate on provider communication, outreach, training, and engagement.
• Lead cross-functional resolution of systemic issues involving claims, configuration, and payment accuracy.
• Provide strategic leadership for value-based payment programs and alternatives.
• Oversee design and optimization of VBP arrangements across provider segments.
• Partner with Medical Economics to develop financial models and benchmarks.
• Align contracting strategies with value-based program objectives.
• Drive provider adoption and maturation along the value-based continuum.
• Establish performance measurement frameworks for provider quality and total cost of care.
• Oversee provider-facing dashboards and internal reporting for VBP and network perf.
• Leverage data analytics for engagement strategies and financial optimization.
• Oversee payment model implementation and monitoring.
• Ensure compliance with CMS, Medicaid, and NCQA, including regulatory reporting.
• Maintain provider servicing policies and procedures and build executive relationships.

Skills

Provider Relations Management

Value-Based Payment Programs

Financial Analytics

Leadership in Managed Care

Regulatory Compliance

Education

Bachelor's degree or 6 years of additional experience

Tools

Provider-Facing Dashboards

Reporting Tools

Automation Platforms

Performance Tracking Systems

Data Reporting Systems

Job description

• Lead all aspects of provider servicing operations, including issue resolution, provider education, and relationship management.
• Serve as the escalation point for complex provider issues, ensuring timely resolution and root-cause remediation.
• Establish standardized servicing models, workflows, and performance expectations.
• Collaborate on provider communication, outreach, training, and engagement initiatives.
• Lead cross-functional resolution of systemic provider issues involving claims, configuration, and payment accuracy.
• Provide strategic leadership for value-based payment programs, including shared savings, capitation, pay-for-performance, and alternative payment models.
• Oversee design, implementation, and optimization of VBP arrangements across provider segments.
• Partner with Medical Economics to develop financial models, performance benchmarks, and incentive methodologies.
• Align contracting strategies with value-based program objectives.
• Drive provider adoption and maturation along the value-based continuum through education, analytics, and performance reporting.
• Establish performance measurement frameworks for provider quality, utilization, and total cost of care.
• Oversee provider-facing dashboards and internal reporting for VBP and network performance.
• Leverage data analytics for provider engagement strategies and financial optimization.
• Oversee payment model implementation and monitoring, including configuration and performance tracking.
• Evaluate contract and VBP financial performance, including Medical Cost Ratio (MCR) and trend impact.
• Support negotiation strategy with provider performance and operational risk insights.
• Ensure compliance with federal, state, and accreditation requirements, including CMS, Medicaid, and NCQA.
• Support regulatory reporting and audits.
• Maintain provider servicing and VBP policies and procedures.
• Build strategic relationships with provider organizations and executive stakeholders.
• Lead Joint Operating Committees and provider governance forums.
• Serve as senior liaison between the health plan and provider community.
• Drive continuous improvement in workflows, tools, and technology platforms.
• Partner with IT and analytics teams on provider data, reporting, and automation.
• Lead transformation initiatives linking provider servicing with population health and clinical operations.
• Lead and develop high-performing provider servicing and VBP teams.
• Establish goals, KPIs, and accountability structures aligned with organizational priorities.
• Foster collaboration, innovation, and continuous improvement.

Requirements

• Bachelor’s degree or 6 years of additional experience can be substituted in lieu of degree.
• A minimum of 10 years experience in provider relations, provider contracting, claims processing, correct coding, and customer service in a managed care organization, including 5 years of progressive leadership experience.
• Strong understanding of reimbursement methodologies (FFS, capitation, shared savings, risk-based models).
• Must possess strong communication skills and be comfortable with public speaking.
• Excellent financial and analytics as well as business acumen.
• Familiarity with the operations of sophisticated large integrated delivery systems, innovative business models, complex multi-institutional and multi-market environments, joint ventures, and evolving population health and payment models.
• Ability to inspire, influence and lead change in difficult and complex environments.
• Knowledge of current national health care policies and trends, leadership, management, and quality improvement concepts.
• Remote applicants must be located in the United States, excluding IL, ND, NY, WA, and WY.
• For hybrid applicants within 60 miles of Albuquerque, in-office presence is required Tuesday through Thursday.

Core Competencies

Demonstrates expertise in provider servicing operations, including issue resolution, provider education, and relationship management, while leveraging data analytics for financial optimization and performance measurement in value-based payment programs.

Highest-signal resume keywords

• Provider Relations Management
• Value-Based Payment Programs
• Financial Analytics
• Leadership in Managed Care
• Regulatory Compliance

ATS Optimization Keywords

Hard Skills

• Claims Processing
• Correct Coding
• Reimbursement Methodologies
• Performance Measurement Frameworks
• Contract Negotiation
• Data Analytics
• Financial Modeling
• Payment Model Implementation
• Quality Improvement Concepts
• Population Health Management

Soft Skills

• Strong Communication Skills
• Public Speaking
• Change Leadership
• Collaboration
• Continuous Improvement

Industry Keywords

• Managed Care Organization
• Integrated Delivery Systems
• Joint Ventures
• Health Care Policies
• Accreditation Requirements

Tools & Technologies

• Provider-Facing Dashboards
• Reporting Tools
• Automation Platforms
• Performance Tracking Systems
• Data Reporting Systems