Director of Provider Operations

HealthPartners is hiring a Director of Provider Operations. This role provides strategic and operational leadership for Provider Operations with accountability for provider enrollment provider data and directory operations network maintenance and configuration trading partner connectivity provider portal operations provider data management and provider compliance and regulatory operations. They will direct department strategy people and performance to ensure accurate provider data effective operational execution regulatory readiness and strong cross-functional coordination while leading complex initiatives managing vendor and external partner relationships and representing the organization in industry and regulatory forums to advance business objectives and operational excellence.

MINIMUM QUALIFICATIONS:

• Education Experience or Equivalent Combination:
  • Bachelor degree in health care business public administration IT project management or related field
  • 7 years experience in health care or insurance industry health-related project management provider data/operations or provider network management
  • 5 years in a leadership or management role
• Knowledge Skills and Abilities:
  • Strong understanding of health plan operation workflows from provider contracting to enrollment to claims processing and payments.
  • Working knowledge of regulatory requirements for Medicare Medicaid and Commercial lines of business.
  • Proven ability to lead cross-functional teams and manage complex projects.
  • Proficiency in data analysis and reporting tools (e.g. Excel SQL PowerBI).
  • Excellent communication negotiation and stakeholder management skills.
  • Ability to work in a fast-paced matrixed environment with competing priorities.
  • Strong interpersonal and collaborative skills to lead and influence teams at all levels of the organization.
  • Solid analytical project and financial management skills.
  • Ability to offer creative cost-effective alternatives and options to solve problems and meet customer needs.
  • Strong oral and written communications.

PREFERRED QUALIFICATIONS:

• Education Experience or Equivalent Combination:
  • Education: Masters degree in health care management health care business public administration or related field
  • Experience:10 years of experience in provider operations or network management with 5 years in a senior leadership role overseeing multi-line health plan operations (Commercial Medicare Medicaid)
• Licensure/ Registration/ Certification:
  • Six Sigma or PMP (Project Management Professional) certification
  • CPHQ (Certified Professional in Healthcare Quality)
  • WEDI (Workgroup for Electronic Data Interchange) member
• Knowledge Skills and Abilities:
  • Strong understanding of complex data hierarchies and system architecture
  • Working knowledge of HIPAA transactions and related EDI standards
  • Demonstrated ability to establish monitor and manage service level agreements

  • Experience leveraging automation and AI-enabled solutions within provider data operations

ESSENTIAL DUTIES:

Strategic Leadership (40%):

• 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 (30%):

• 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 (20%):

• 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 (10%):

• 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 (5%):

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

LEADERSHIP RESPONSIBILITY:

Key Areas of Responsibility Include:

Provider Enrollment: Owner of contracted provider enrollment and implementation of various state national or accreditation requirements ensuring accurate and timely provider information is available to health plan members

• Network Participation Management: Partner with Provider Relations & Network Management and other administrative teams to develop networks that meet market needs and maintain regulatory compliance.

• Provider Data Management: In coordination with IT and other administrative systems develop integrated enterprise-wide provider data platform.

• EDI Trading Partnerships: Oversee clearinghouse strategy and monitor to ensure contract compliance.

• Provider portal: Responsible for secure account registration management fraud mitigation and escalation if potential fraud is identified. Monitor effectiveness of portal and impacts to call centers.

• 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.