Location Address:


Summary:
Presbyterian Healthcare Services (PHS) seeks a highly strategic and analytically driven executive to serve as Executive Director of Provider Network Oversight for Presbyterian Health Plan. This is a critical enterprise leadership role responsible for ensuring the integrity, compliance, and performance of the health plan's provider network-spanning regulatory oversight, financial accuracy, vendor governance, and provider data excellence.

In an environment of increasing regulatory scrutiny and complexity across Medicare, Medicaid, and Commercial products, this leader will play a pivotal role in ensuring the organization meets and exceeds network adequacy, access, and transparency requirements while optimizing provider network performance and member experience.

With oversight of $4B+ in provider payments and $100M+ in vendor relationships, this role is uniquely positioned at the intersection of finance, provider strategy, operations, and compliance. The Executive Director will partner broadly across the organization to deliver best-in-class network oversight and enable strategic growth through data-driven insights and strong governance.

Work Arrangement:
• Remote: Open to applicants in the United States, excluding CA, IL, ND, NY, OH, WA, and WY.
• Hybrid: For individuals within 60 miles of Albuquerque, in-office presence is required Tuesday through Thursday.

Job Description:

Network Adequacy & Regulatory Leadership

• Define and lead enterprise network adequacy strategy, ensuring compliance with CMS, state Medicaid, Marketplace, and Department of Insurance requirements
• Oversee development, validation, and submission of regulatory filings, attestations, and audit responses across all lines of business
• Serve as senior liaison with regulators, ensuring transparency and alignment on provider access, directory accuracy, and compliance standards
• Ensure adherence to mental health parity and access requirements through partnership with network strategy teams

Provider Data Governance & Directory Excellence

• Establish enterprise provider data governance strategy to ensure accuracy, completeness, and consistency across systems
• Lead provider directory operations, including audits, correction workflows, and regulatory documentation
• Ensure compliance with CMS, NAIC, and state requirements for directory accuracy, timeliness, and transparency
• Partner with IT to enhance provider data systems, automation, and reporting capabilities

Vendor & Network Ecosystem Oversight

• Lead enterprise strategy, governance, and performance management for national, regional, and wrap provider networks
• Oversee vendor portfolio exceeding $100M annually, including contract performance, SLAs, and regulatory compliance
• Establish and monitor KPIs for vendor performance, ensuring timely remediation of deficiencies
• Ensure seamless integration of external networks into internal systems, reporting, and member-facing tools

Financial Integrity & Contract Conformance

• Oversee contract conformance monitoring and financial analysis of $4B+ in provider payments
• Partner with Medical Economics and Finance to ensure reimbursement accuracy and identify areas for improvement
• Develop reporting and auditing frameworks to ensure compliance with contractual terms and mitigate financial risk

Analytics, Reporting & Performance Management

• Establish network adequacy dashboards, KPIs, and reporting frameworks to identify access risks and network gaps
• Provide executive-level insights and recommendations to leadership and governance committees
• Lead performance review processes to drive accountability and continuous improvement

Leadership & Cross-Functional Collaboration

• Build and lead high-performing teams across provider data, network adequacy, and vendor oversight functions
• Foster strong collaboration across Finance, IT, Operations, Compliance, and Provider-facing teams
• Support enterprise initiatives related to product design, network expansion, and value-based care

Success Measures

Within the first 12-24 months, the Executive Director will:

• Ensure Regulatory Excellence: Achieve consistent compliance with all network adequacy and provider directory requirements across lines of business
• Strengthen Data Integrity: Improve provider data accuracy, completeness, and system integration across the enterprise
• Enhance Financial Oversight: Optimize contract conformance processes and identify opportunities to improve provider payment accuracy
• Elevate Vendor Performance: Strengthen governance and accountability across external network partners and delegated entities
• Advance Network Strategy: Deliver actionable insights that improve access, close network gaps, and support strategic growth

Additional Job Description:

Education

• Required: Bachelor's degree in Healthcare Administration, Business Administration, Information Systems, Public Health, or related field
• Preferred: Master's degree (MBA, MHA, or related discipline)

Knowledge & Work Experience

• Minimum of 10+ years of progressive experience in provider network management, provider data operations, regulatory reporting, or health plan compliance
• At least 5 years of senior leadership experience overseeing enterprise-level teams and vendor relationships
• Deep expertise in:
  
  • Network adequacy regulations (CMS, Medicaid, Marketplace)
  • Provider directory requirements and compliance standards
  • Healthcare finance and reimbursement
  • Contract conformance, audit processes, and internal controls
  • National and wrap network models and delegated arrangements

Core Competencies

• Regulatory Expert: Deep understanding of federal and state network adequacy and transparency requirements
• Financial & Analytical Strength: Ability to oversee large-scale financial operations and translate data into actionable insights
• Systems Thinker: Expertise in provider data ecosystems, technology integration, and process optimization
• Executive Communicator: Strong presence with the ability to engage regulators, vendors, and senior leadership
• Operational Leader: Proven ability to lead complex, cross-functional initiatives in matrixed environments
• Relationship Builder: Skilled at managing internal and external partnerships with influence and credibility
• Change Leader: Drives continuous improvement in highly regulated, evolving environments

Benefits
Benefits are effective day-one (for .45 FTE and above) and include:

• Competitive salaries
• Full medical, dental and vision insurance
• Flexible spending accounts (FSAs)
• Free wellness programs
• Paid time off (PTO)
• Retirement plans, including matching employer contributions
• Continuing education and career development opportunities
• Life insurance and short/long term disability programs