Director - Provider Relations

Description

• Put Patients First
• Empower Entrepreneurial Provider and Care Teams
• Operate with Integrity & Excellence
• Be Innovative
• Work As One Team

What You'll Do

• Develop and execute provider engagement and performance improvement strategies aligned with organizational and market goals
• Lead provider-facing initiatives focused on quality improvement, risk adjustment, utilization management, value-based care performance, and financial sustainability
• Partner with provider organizations to drive practice transformation, workflow optimization, care coordination, and population health management initiatives
• Monitor provider performance against key metrics and develop action plans to improve quality outcomes, coding accuracy, documentation, utilization, and cost of care
• Serve as a strategic advisor and executive sponsor for key provider organizations and partnerships
• Collaborate with internal teams to address provider operational issues related to claims, authorizations, credentialing, rosters, directory accuracy, and delegated services
• Support network development, provider retention, network optimization, and market expansion initiatives
• Lead provider education efforts related to HEDIS, CMS Star Ratings, risk adjustment, value-based care programs, and regulatory requirements
• Analyze provider, clinical, operational, utilization, and financial performance data to identify trends and improvement opportunities
• Develop executive-level reporting and present provider performance updates, recommendations, and strategic initiatives to leadership and stakeholders
• Lead, mentor, and develop Provider Relations Managers and market-based provider engagement teams
• Foster a culture of accountability, collaboration, continuous improvement, and performance excellence

Qualifications

• Bachelor's degree in Healthcare Administration, Business Administration, Nursing, Public Health, Finance, or a related field
• Minimum of 8 years of healthcare leadership experience in Provider Relations, Managed Care, Value-Based Care, Population Health, IPA Operations, ACO Operations, or Network Performance
• Minimum of 5 years of progressive leadership experience managing provider-facing teams
• Demonstrated success leading provider performance improvement initiatives
• Experience working with Medicare Advantage, Medicaid, Commercial, and Value-Based Care programs
• Experience managing complex provider networks, delegated arrangements, and strategic provider partnerships
• Strong understanding of physician practice operations, managed care, and value-based care delivery models
• Expertise in practice transformation, provider engagement, population health management, and performance improvement strategies
• Strong knowledge of HEDIS, CMS Star Ratings, risk adjustment, RAF methodology, utilization management, and medical cost management
• Experience developing provider scorecards, performance improvement plans, and corrective action strategies
• Advanced proficiency in Microsoft Excel and PowerPoint
• Strong analytical, presentation, communication, facilitation, and negotiation skills
• Ability to translate complex clinical, operational, and financial data into actionable provider strategies
• Knowledge of applicable federal, state, CMS, and contractual requirements governing provider networks and healthcare programs

• Master's degree in Healthcare Administration, Business Administration, Public Health, Nursing, or a related field
• Experience with ACO REACH, MSSP, Medicare Advantage, Medicaid, Commercial, and other risk-bearing or value-based arrangements
• Experience with clinical documentation improvement and EHR optimization initiatives
• Experience supporting new market, payer, product, or provider-network implementations
• Professional certification such as CPHQ, CPC, CCS, PMP, Lean Six Sigma, or a similar healthcare or project management credential

Environmental Job Requirements and Working Conditions

• Full-time leadership position supporting provider networks and value-based care initiatives across assigned markets
• Frequent use of a computer, telephone, and standard office equipment
• Ability to work in a fast-paced environment while managing multiple priorities and strategic initiatives
• Regular collaboration with providers, executive leadership, health plans, and cross-functional teams
• Travel may be required to support provider engagement, market operations, and business needs