Provider Network Operations Director (Remote-NC)

Position eligible for – 

• Annual incentive bonus plan
• Medical, dental, and vision insurance with low deductible/low cost health plan
• Generous vacation and sick time accrual
• 12 paid holidays
• State Retirement (pension plan)
• 401(k) Plan with employer match
• Company paid life and disability insurance
• Wellness Programs
• Public Service Loan Forgiveness Qualifying Employer

See attachment for additional details. 

Office Location:  Available for any of Partners' NC locations; Remote option-NC.

Projected Hiring Range:  Depending on Experience

Closing Date:   Open Until Filled

Primary Purpose of Position: The Provider Network Operations Director for the Provider Network Team will lead the operational strategy, execution, and continuous improvement of the organization’s provider network. This role will ensure that network design, credentialing, enrollment, data integrity, regulatory compliance, and provider operations are aligned with the organization’s mission, performance goals, accreditation and payer standards. 

The Director will partner closely with senior leadership (Executive Director Provider Network, Operations team, Executive leadership ELT) to ensure the network supports growth, quality, access, and member focused outcomes.  

The Provider Network Operations Director provides oversight in the development and management of the Provider Network for those members/recipients who have been identified as having Serious Mental Health or Intellectual/Developmental Disabilities enrolled in Partners’ Health Plan. The Provider Network Operations Director provides leadership and administrative direction for the development of a comprehensive array of services and supports for members/recipients as well as development of requests for proposals to close gaps in the provider network across the service array. The Provider Network Director of Operations ensures the network is in compliance with contractual and state standards.  

This position will oversee and be responsible for enrolling, contracting, developing and managing network operations to ensure compliance with network expectations are met by internal and external standards. This position provides leadership to ensure processes and workflows are in place to manage provider data management operations and has knowledge and understanding of statewide credentialing processes as well and accreditation standards. The Provider Network Director of Operations works collaboratively across departments to ensure member/recipient access to services. 

Roles and Responsibilities:  

• Develop and implement department and unit policies, procedures, and goals that align with organizational goals and national accreditation standards, as well as ensure contractual compliance.  
• Work with the Provider Network Leadership, Operations team, and other cross functional teams or business units to establish goals and address the needs of the Network of Providers
• Ensure that all network programs and systems are developed in accordance with Local, State, and Federal performance standards and congruent with organizational and procedural manuals
• Ensure National Accreditation (NCQA) requirements are documented and are met for Provider Network as indicated.
• Work with the Sr. Director of Provider Network to plan, develop and implement goals, policies, and procedures
• In conjunction with the Sr. Director of Provider Network, review and revise policies and procedures pertaining to the implementation and development of a comprehensive array of providers
• Serves in a leadership role with external departments and with Provider Network Leadership to develop policies and procedures for health plan operations i.e., Medicaid Direct and Tailored Plan operations
• Assure compliance with external quality standards and national accreditation standards.  

Network Support and Program Development: 

• Serves as operational lead for provider enrollment, credentialing and re-credentialing processes – ensuring that the network is populated with qualified, contracted providers according to defined scope, service types, geographic coverage, and regulatory requirements.
• Works with the Contracts Team to develop contracts for providers and practitioners to support and maximize member and recipient access to care and to ensure compliance with contractual and national accreditation requirements.  
• Enrolls providers in the Network according to parameters determined for qualifications and needs of the Network for service providers; assures enrollment of provider profile information into the IT system  
• Serves as a liaison between the providers and internal departments; meets with the administration of provider agencies and Board members as needed to facilitate the goals of the Network, meet consumer needs and enhance relationships  
• Maintains leadership role in the completion of the annual capacity study in an effort to identify gaps in services and address the needs of the community
• Maintains leadership role in submission of state required reporting related to provider data.
• Providers leadership and oversees processes related to the issuance of provider sanctions and terminations and the provider appeals process.
• Implements the network philosophy to ensure development of provider choice and development of new services provided in accordance with Best Practices and identified community needs/ gaps.  
• Assesses current service capacity and assumes a leadership role with the development of Requests for Proposals, Requests for Information and Selective Recruitment to facilitate development of a comprehensive array of services that address the needs of the consumers
• Oversees the technical functions of the provider enrollment processes to ensure compliance with Tailored Plan and Medicaid Direct operations
• Oversees and maintains reporting responsibilities as outlined in the Tailored Plan and Medicaid Direct Plan regarding network adequacy, availability, enrollment and contracting
• Works to ensure provider data is accurate for the purposes of the provider directory
• Works to ensure provider portal data processes and workflows are in place to manage the implementation of a provider portal in compliance with Tailored Plan requirements.  
• Provides technical assistance and guidance as necessary

Staff Management and Development 

• Sets performance goals, deadlines and KPIs for the team that align with the broader organizational vision; provide ongoing coaching, feedback and professional development opportunities.
• Leads, mentors and develops the provider network operations team to ensure a well-trained, high-performing workforce aligned with operational goals.  Ensure staff are well trained in and comply with all organizational and department policies, procedures and business processes
• Organize workflows and ensure staff understand their roles and responsibilities
• Ensure the department has the necessary tools and resources to achieve organizational goals and top support employees with compliance with licensure, regulatory, and accreditation requirements
• Ensure that staff are treated with dignity and respect
• Work to ensure standards are transparent and applied consistently, impartially and ethically over time and across all staff members
• Set performance goals and deadlines in line with organization goals and vision
• Effectively communicate feedback and provide ongoing coaching and mentoring to staff and support a learning environment to advance team skills, professional development and that embraces and embodies Partners’ culture
• Fosters a culture of collaboration, transparency, respect and continuous improvement; encourage cross-team partnership (e.g., clinical operations, product teams, analytics) and adoption of best practices.

Collaborate and Communicate: 

• Directs the assistance for consumers and families as requested in negotiating issues pertinent to service implementation and providers
• Follows up and manages provider dispute resolution process on behalf of assigned provider agencies to include mediation of the complaint(s) with all parties; fosters a solution focused atmosphere in the Network  
• Supports and facilitates consumer and family involvement and the development of Best Practices in the provider agencies, addressing a comprehensive system of care which will utilize natural supports in the community
• Provides a community presence to promote the Network and available services
• Communicate effectively with other Departments to follow up on any provider operations, contracting or enrollment issues

Knowledge, Skills and Abilities:  

• Comprehensive knowledge of mental health, substance use and intellectual and developmental disabilities and service delivery systems for the entire spectrum of client categories including an understanding of principles, concepts and Best Practices used in the treatment, habilitation and support of individuals with needs in any of the disability areas
• Comprehensive knowledge of Strategic Planning, Network Adequacy, provider data management and Quality Management principles.  
• Must have knowledge of Medicaid Transformation, Local Management Entity functions and Managed Care
• Knowledge of the laws, regulations and programs impacting mentally ill, substance abusing and intellectually and developmentally disabled clients and their families
• Must understand LME/MCO goals, targets and outcomes in relation to the responsibilities and supporting relationships of the Network Management Department
• A high level of diplomacy and discretion is required to effectively negotiate and resolve issues with minimal assistance, requiring exceptional interpersonal skills, teambuilding skills, highly effective communication ability, and the propensity to make prompt independent decisions based upon relevant facts
• Problem solving, negotiation, arbitration, and conflict resolution skills are essential to balance the needs of both internal and external customers
• Requires public speaking and mediation skills in order to facilitate collaboration and positive relationships between teams, families/consumers and agencies
• Excellent computer skills including proficiency in Microsoft Office products (such as Word, Excel, Outlook, PowerPoint)
• Ability to identify/analyze administrative problems pertinent to the contract, make independent judgments, logical conclusions, recommendations and decisions
• Ability to review and analyze data in an effort to evaluate program effectiveness, progress, problems and system performance
• Ability to establish and maintain positive and effective working relationships with leadership and staff, stakeholders and local/state/federal officials

Education/Experience Required: Bachelor’s Degree in mental health, public health, social work, psychology, education, sociology, business or public administration and five (5) years of experience in a community, business, or governmental program in health related fields, social work or education including experience in network operations, provider relations and management experience. Three (3) years of supervisory, consultative or administrative experience. A combination of relevant experience may be considered in lieu of a bachelor’s degree. Must have ability to travel as needed to perform job duties. NC Residency is required.  

Education/Experience Preferred: Master’s Degree in mental health, public health, social work, psychology, education, sociology, business or public administration and five (5) years of experience in a community, business, or governmental program in health related fields, social work or education including experience in network operations, provider relations and management experience. Three (3) years of supervisory, consultative or administrative experience. NC Residency is required. 

Licensure/Certification Requirements: None