Director Of Network Operations

Job Requirements

Position Summary

The Director of Network Operations is a leadership role responsible for strengthening Regional HealthPlus (RHP)'s provider network operations in support of RHP's work as Spartanburg Regional Healthcare System (SRHS)'s clinically integrated network (CIN/PHO). This position ensures the network is positioned to succeed across both fee-for-service and value-based contract arrangements by leading core provider operations that connect payors, SRHS-owned facilities and providers, and aligned non-owned facilities and providers. The Director builds trusted relationships with network stakeholders, facilitates execution of performance improvement initiatives, and coordinates closely with subject matter experts to deliver measurable results. Collaboration, strong project management, and clear communication skills are essential. The Director is a well-rounded leader with broad experience in both payor-facing and provider-facing operations, with a practical, analytical approach to problem solving applicable to any leadership challenge.

Minimum Requirements

Education

• Bachelor's degree in healthcare administration, business administration, or a related field required

Experience

• Minimum of eight years of progressive experience in healthcare, health plan, managed care, or provider network operations roles

License/Registration/Certifications

• N/A

Other Knowledge, Skills, and Abilities

• Significant cross-functional experience leading collaborative projects and operational initiatives across multiple stakeholders
• Demonstrated leadership, team-building, and relationship management skills
• Strong knowledge of provider network operations
• Strong understanding of health insurance, managed care contracting, and value-based care models
• Familiar with provider credentialing and payor enrollment/load processes
• Strong organizational, verbal, and written communication skills required

Preferred Requirements

Preferred Education

• Masters degree

Preferred Experience

• N/A

Preferred License/Registration/Certifications

• N/A

Core Job Responsibilities

Provider Engagement

• Responsible for the overall composition, effectiveness, and strategic alignment of the RHP provider network, including oversight of provider access, network adequacy, provider assignment and attribution, network integrity, and related recommendations for improvement
• Recruit, onboard, and retain providers and facilities within the RHP network that are determined to be strategically aligned
• Oversee participating provider membership and related operational processes
• Ensure timely, professional, and well-documented communications to RHP providers related to network strategy and provider engagement priorities
• Provide independent participating providers with managed care operational support, including staff education, payor in-service meetings, and escalated claims resolution as needed
• Monitor applicable market and industry trends that may affect provider network composition, access, adequacy, and strategic alignment
• Coordinate implementation of performance improvement initiatives across network providers and key stakeholders, including employed and non-employed providers, hospitals, ambulatory surgery centers, skilled nursing facilities, and other network participants

Payor Engagement

• Maintain strong working relationships with appropriate payor representatives to support collaboration, operational alignment, and timely issue resolution
• Lead reconciliation of provider assignment and patient attribution rosters between payors and providers to improve operational accuracy, performance measurement, and financial outcomes
• Collaborate with payors and internal stakeholders to operationalize bundled payment and other alternative payment models, including the South Carolina Healthy Connections Quality Achievement Program (QAP)
• As needed, lead network-wide operational improvement initiatives involving independent provider interoperability, reporting, CMS innovation models or pilots, and other strategic initiatives
• Oversee RHP delegated credentialing agreements with payors and ensure compliance with contractual, regulatory, and audit requirements
• Work collaboratively within a matrixed environment to resolve issues related to payor provider directories, and claims system uploads to improve accuracy, timeliness, provider access, and network integrity

Value-Based Care and Alternative Payment Model Performance Management

• Strong working knowledge of MSSP program requirements, benchmarking methodologies, and accountable care operations.
• Subject matter expert for episodic care models, including bundled payment models, and other alternative payment models
• Closely monitor performance and identify drivers of variation, including utilization patterns, cost of care, post-acute spending, and quality outcomes
• Coordinate operational readiness and implementation activities required to support contractual performance objectives
• Help ensure that population health programs are scalable, measurable, and integrated into routine clinical and practice operations
• Support contractual/financial reconciliation processes related to bundled payment programs and other alternative payment models
• Drive development of dashboards, scorecards, and performance monitoring tools related to episodic care models and other alternative payment models that support action by leaders, providers, and operational teams

Spartanburg Regional Healthcare System Employee Health Plan

• Support administration of the SRHS Employee Health Plan, a full-risk health plan for the system, including provider network contracting, operations and associated reporting
• Collaborate with Human Resources, healthcare consultants, the third-party administrator (TPA), and pharmacy benefit manager (PBM) on plan operations, performance, and strategic initiatives
• Lead development of plan performance reporting to support operational oversight, decision-making, budget forecasting, and ongoing improvement
• Lead the medical management and utilization review team in support of plan performance, appropriate utilization, and care management objectives
• Oversee direct contracting arrangements and associated reporting for the SRHS Employee Health Plan

Project Management and Collaboration

• Lead and coordinate cross-functional projects related to network operations, value-based care contracts and alternative payment model performance, employee health plan performance, and other strategic initiatives
• Lead and coordinate cross-functional projects related to network operations, value-based care contracts and alternative payment model performance, employee health plan performance, and other strategic initiatives
• Provide administrative leadership and operational support for the Membership and Participation Committee
• Participate in selected RHP, SRHS, and SEHP committees and workgroups to support network operations and strategic initiatives
• Represent RHP in collaborative efforts with internal SRHS departments, non-owned providers, and other provider and administrative stakeholders
• Coordinate with Southeastern Health Partners and other strategically aligned partners on shared network, operational, and strategic initiatives
• Coordinate with Provider Engagement and Performance Committee in support of the provider disciplinary process, as needed
• Support departmental planning, prioritization, and execution of key operational and strategic initiatives

Other duties as assigned