Director of Provider Network Operations

Role Overview : The Director of Provider Network Operations is responsible for overseeing and managing all local operational functions to ensure efficient performance and compliance. This role ensures that all plan policies and procedures meet applicable regulatory standards, gain appropriate stakeholder approval, and that any downstream impacts of operational or policy changes are clearly communicated to providers and internal systems. The Director also serves as a key representative for the organization during Department of Health and Hospitals (DHH) meetings and scheduled events.

Work Arrangement:

• Hybrid – Associate must be in the office at least two (2) days per week at our Baton Rouge, Louisiana (LA) location, including core days of Tuesday and Wednesday.
• Required to attend and represent AmeriHealth Caritas Louisiana (ACLA) at DHH meetings, events, and other scheduled sessions.

Responsibilities:

• Oversee the full operations of the provider network.
• Ensure the accuracy and completeness of provider data as the initial entry point into Enterprise systems.
• Maintain a working and strategic understanding of medical billing principles, including ICD ‑ 9, ICD ‑ 10, CPT codes, and related documentation requirements.
• Translate contract provisions accurately and in a timely manner into Facets, including analysis and modification of business processes to support efficient contract operations.
• Lead provider and claims education efforts and maintain provider directory accuracy.
• Present new ideas aligned with continuous quality improvement (CQI) principles and motivate teams to apply CQI in daily work.
• Collaborate effectively across all levels of management, building strong relationships and supporting cross-functional problem-solving.
• Foster team collaboration, share information proactively, and prioritize team goals.

Education & Experience:

• Bachelor’s degree required
• 8 years of progressive business management experience, preferably within healthcare.
• 5 years of management experience in a managed care environment, including leading teams and managing complex projects.
• 3 years of managed care experience in provider reimbursement, contracting, or claims.
• 1 to 2 years of Medicaid experience preferred.
• Previous experience developing and delivering presentations.
• HIPAA, NCQA, and Facets experience preferred.
• Previous experience managing client-facing relationships is advantageous.

Skills & Abilities:

• Strong functional knowledge of the operations department workflows.
• Ability to make administrative and procedural decisions on sensitive and confidential issues.
• Skilled in examining and re-engineering operational processes, formulating policy, and implementing new strategies.
• Strong communication skills, including active listening and effective feedback delivery.
• Ability to work effectively with diverse constituencies and across all levels of management.
• Demonstrated leadership in developing, coaching, and motivating team members.
• Proven ability to collaborate, share information freely, and build on team ideas to solve problems.
• Commitment to continuous quality improvement and operational excellence.