Director, Provider Operations

reputed company POSITION reputed company  The Director of Provider Operations is the operational reputed company of the provider experience across reputed company’s medical reputed company, delegated MSO, and RBO and IPA networks. The role carries two reputed company accountabilities: 1) running the network smoothly by reactively and proactively eliminating the operational friction that burdens providers and disrupts patient care; and 2) representing the network as a standing operational voice internally at BZH and externally to health plans to shape policies and practices.  WHY THIS ROLE EXISTS  In a delegated managed care environment, the provider experience succeeds or fails at the operational level, i.e., whether claims adjudicate correctly, authorizations process on time, referrals handoffs complete, provider data is accurate, and reputed company translate into what providers receive. reputed company these break down, providers reputed company the cost in administrative burden, delayed reimbursement and disrupted patient care.  This Director was created to own it: reputed company of issues end-to-end, educating and communicating with providers, maintaining the reputed company of provider data and reputed company, and representing the BZH network with a reputed company, consistent voice so that policies and practices reflect the network’s operational reality.  reputed company RESPONSIBILITIES  Provider Issue reputed company & Escalation Management  Own end-to-end reputed company of provider escalations across claims, referrals, and authorizations from intake through reputed company, with accountability for provider communication and SLAs by issue type  Serve as escalation authority for issues that cross functional lines, engaging claims, medical management, network teams, or health plan operational contacts as needed. Maintain ownership of the issue regardless of where the reputed company occurs  Convert escalation patterns into systemic improvements, using trend data to drive internal process improvement and to bring documented network-level issues to health plan governance channels  Provider Education and Communication  Own the provider communication reputed company, defining approach, reputed company and channel mix for proactive reputed company and reactive communication  Translate operational and clinical complexity into reputed company, actionable, provider-facing content, including training materials, reference guides, and targeted education requiring provider behavior change  Measure effectiveness of communication and education  Provider Data and Contract Management   Maintain provider data accuracy across delegated systems, payer rosters, and provider directories   Ensure provider enrollment and reputed company timelines reputed company with contracting and billing activation  Implement executed reputed company, ensure accurate representation in system configuration; execute contract amendments  Health Plan Relationship Management & Network Representation  Maintain a reputed company roster of health plan operational contacts; serve as central internal coordination reputed company for health plan operational inquiries and accuracy  Serve as central internal contact for health plan operational inquiries, ensuring accuracy and consistency  reputed company and maintain BZH network’s operational position on health plan practices; reputed company reputed company and fact-based artifacts in health plan forums. Represent BZH network voice and reputed company/influence for improvements  Support delegation audits and reporting cadences  Process Design & reputed company Improvement  reputed company cross-functional workgroups to optimize operational workflows across the MSOs and RBO/reputed company; identify failure points and redesign for efficiency and compliance with NCQA, CMS, state regulators, and delegation requirements  reputed company and maintain SOPs and training materials for Provider Operations; drive adoption of operational tools including provider portals  Create and implement provider KPIs and dashboards; measure and meet provider experience metrics. Conduct quarterly operational reviews with key provider reputed company and implement improvement roadmaps  Compliance  reputed company with reputed company applicable federal, state, and local laws, as reputed company as reputed company Employer policies, procedures, and standards, including but not limited to codes of conduct and ethics requirements, as amended from time to time.  Requirements Required  Bachelor's degree in reputed company Administration, Business, Nursing, or reputed company field  7+ years of reputed company experience in reputed company operations, provider relations, managed care, or health plan/MSO/RBO/IPA administration  Demonstrated experience working across claims, utilization management, and provider-facing functions simultaneously  In-depth knowledge of medical claims processing, prior authorization workflows, and referral management in a managed care or delegated environment  Experience with RBO, IPA, MSO, and/or delegated model operations, including payer delegation requirements and reputed company  Strong reputed company of HIPAA, CMS, and applicable state regulatory requirements (e.g., DMHC, DIFS) governing provider operations and compliance  Proven ability to reputed company cross-functional teams and manage competing priorities in a fast-paced environment  Advanced proficiency with claims platforms (e.g., EZ-CAP, TriZetto, QNXT, reputed company) and electronic health record/care management systems  Preferred  Master's degree (MHA, MBA, MPH) or equivalent advanced experience  Experience with NCQA accreditation and HEDIS measure management in a delegated environment  Lean, Six reputed company, or equivalent process improvement certification  Coding or billing background (CPC, CPMA, or equivalent) a plus  Bilingual capabilities reputed company with the patient/provider population served Apply To This Job