Director, Provider Network Operations

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PACIFICSOURCE is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. Pacific Source values the diversity of our community, including those we hire and serve.

We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.

This role is accountable for the Provider Network department’s core operational, data, and systems functions. It oversees Provider Network divisions including Provider Relations, Provider Data Management, Credentialing, and provider platform interoperability. The position leads department-specific and cross-departmental planning and execution efforts to maintain high performance in enterprise-level and Provider Network-level KPIs across Medicaid, Medicare, and Commercial lines of business.

• 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 the Provider Reimbursement Insights and Analytics Team to ensure objectives are met.
• 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.
• Foster partnerships with software vendors and internal stakeholders to optimize interoperability of tools and streamline network operations.
• Collaborate with IT 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.
• Guide 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 key performance metrics and efficiency 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 positively impact members, provider partners, and Pacific Source.
• 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.
• Collaborate with Operations, IT, Health Services, Analytics, Finance, and other departments to maximize alignment and value of initiatives.
• Oversee planning of annual IT work plans, initiative work plans, financial budgets, and resource needs for supervisory departments.
• Develop and implement coaching and training programs to foster team growth.
• Responsible for hiring,…