Position Purpose: The Director of Provider Operations is responsible for directing the operations of the HNFS health plan’s credentialing, provider credentialing appeals, provider sanction monitoring, contract processing, provider data management, provider management databases (credentialing, contracting, verification, etc) and ensuring compliance with Health Net standards for participation, service level agreements, state/federal regulatory requirements and accrediting entity credentialing standards. The Director collaborates with other departments to assure smooth flow of contract, credentialing information and provider data information. The Director oversees provider directory functions, change order implementations and web information. The Director also negotiates and maintains service contracts, develops and implements policies and procedures, and completes regular audits. The Director works collaboratively with other functions to achieve business unit and overall company results and to share best practices.
- Directs and ensures the effective and efficient operational management of multiple functions with an emphasis on execution, outcomes, continual improvement and performance enhancement.
- Oversees the several functional areas including: credentialing, contract processing, provider data management, department reporting, and database operations for all service areas such as, the development, implementation and maintenance of criteria, policies and procedures.
- Oversees credentialing and Delegated Credentialing arrangements; reviews and verifies activities of all departments and guarantees that criteria and implementation fulfills accrediting, certification and regulatory requirements.
- Oversees the development and execution of provider appeal process related to credentialing, including legal consultations, reconsiderations, fair hearings, regulatory agency reporting and related business functions.
- Develops and implements quality/accuracy audit and reporting capabilities across all areas of PNM.
- Leads operations and cross-functional teams to support quality improvement programs and quality-related goals.
- Develops/manages human resources and sets performance expectations; develops and mentors staff in an environment where customer needs are the primary focus; develops and implements recruitment and retention plans to ensure adequate availability of resources; provides performance evaluations, development, motivation, counseling, guidance and training to all associates.
- Ensures compliance with all regulatory, accreditation, certification and internal requirements; oversees activities related to any Credentials Verification Organizations; develops processes and procedures to ensure compliance; follows up on all state/federal sanction and disciplinary action reports.
- Works collaboratively with delegation oversight to ensure delegated entity compliance with credentialing standards and policies.
- Works collaboratively with subcontractor oversight to ensure subcontractor compliance with provider certification and privileging requirements related to government programs (DoD, Veteran Affairs, etc.)
- Works across departments/functions to ensure processes, metrics and service levels are compliant.
- Leads business and system development, program development and development of integration models to increase the efficiency and effectiveness of service. Ensures all functional change orders are planned and implemented.
- Develops systems and databases to capture all necessary provider information; ensures all data is accurate and current; ensures all government reporting is correct and timely.
- Provides subject matter expertise and support to RFP and RFI process.
- Oversees collaborative effort with Provider Network Management and other business units/divisions on vendor relationships and implementation.
- Actively participates in and/or leads business unit-wide initiatives; represents Credentialing and Provider data management during business unit-wide discussions and activities; provides subject matter expertise to business unit.
- Responsible for fiscal management/leadership, such as budgeting, reporting and productivity.
- Performs other duties as required.
Education/Experience: Bachelor’s Degree. Master’s Degree preferred. Minimum five years of credentialing experience in a managed care setting. Minimum five years progressively responsible management experience. Minimum five years of health plan experience.