Director of Provider Operations

Strategic Leadership

Develop and execute a comprehensive provider operations strategy aligned with organizational goals and regulatory requirements. Partner with IT and other health plan system owners to develop an integrated enterprise-wide provider data platform. Lead cross-functional initiatives to enhance provider data accuracy and implement cost effective enrollment processes to facilitate quick provider on-boarding, claims submissions and provider payments.

Provider Enrollment Oversight

Oversee contracted provider end-to-end provider data lifecycle including intake of roster and enrollment forms, maintenance of provider data, network participation management, clearinghouse, EFT and web portal enrollment. Oversee vendor relationships and performance, ensuring accountability and ROI.

Compliance & Quality

Ensure adherence to federal and state regulations, including CMS and Medicaid guidelines. Collaborate with Provider Relations & Network Management, Legal, Compliance, and Claims teams to mitigate risk and ensure audit readiness.

Analytics & Reporting

Leverage analytics to identify trends, root causes, and opportunities for improvement. Develop and present executive-level reporting on savings, compliance and workload impacts. Monitor data accuracy and turnaround times to ensure internal or compliance goals are met.

Team Development

Build and lead a high-performing team of analysts, auditors, and managers. Foster a culture of continuous improvement, innovation, and accountability.

Innovation (R&D)

Conducts research and development to support compliance needs and cost-effective workflow improvements to support functions of the department. Identify and gather ideas from other sources (internally & externally). Assess use and enablement of advanced technologies (AI, gLLM, etc…) with IT input.