Director, Provider Relations

Position Summary:
The Director of Provider Relations leads the strategic vision and operational execution of provider relations for Commonwealth Care Alliance's SCO and One Care lines of business. This role is responsible for cultivating high-impact relationships with key healthcare providers, optimizing network performance, and ensuring compliance with regulatory standards. The Director drives initiatives that enhance operational engagement, member access, provider satisfaction, and value-based care outcomes, while serving as the primary liaison for escalated provider matters.

This position partners closely with provider engagement, delegation partnerships, provider services, contracting, quality, compliance, medical management, and analytics teams to advance provider network operations, education, and performance improvement.

The Provider Relations Director reports to the Sr Director of Delegation Partnerships and Provider Engagement.

Supervision Exercised:
* Yes, this position does have direct reports including Provider Relations Account Managers.

Essential Duties & Responsibilities:
Provider Relationship Management
* Develop and execute the organization's provider relations strategy, ensuring strong, collaborative partnerships with hospitals, physician groups, LTSS, HCBS, behavioral health, and ancillary providers.
* Serve as the primary point of contact for high-priority provider groups, resolving escalated and complex issues with a focus on long-term satisfaction and retention.
* Lead ongoing communication efforts, working closely with Provider Communications Manager, to keep providers informed of organizational objectives, regulatory updates, operational changes, and compliance requirements.
* Establish and oversee a structured process for tracking, escalating, and resolving provider issues in coordination with network, operational, clinical, and compliance teams.

Network Performance & Compliance
* Collaborate with contracting, operations, and analytics teams to monitor network performance against internal and regulatory benchmarks.
* Ensure provider network compliance with CMS, state Medicaid agency, and NCQA standards.
* Lead initiatives to streamline provider operations, reduce administrative burden, and improve the overall provider experience.
* Analyze trends in provider inquiries and grievances to identify root causes, recommend process improvements, and enhance provider satisfaction and performance.
* Partner with senior leaders to communicate resolution and outcomes and drive cross-functional accountability for systemic improvements.
* Ensure all issue resolution processes align with regulatory requirements and organizational standards for service quality and responsiveness.

Provider education
* Collaborate with Provider Communications, Provider Engagement and Delegation in the development and execution of a comprehensive provider education strategy.
* Oversee the design and delivery of high-impact training programs, webinars, and materials that strengthen provider understanding of CCA's model of care, operations, and compliance standards.
* Partner with internal stakeholders to ensure educational initiatives support system-wide consistency and continuous improvement.
* Leverage data and provider feedback to identify educational needs, measure effectiveness, and adapt programs for maximum impact.
* Represent CCA as a thought leader in provider education at meetings, forums, and partnerships.
* Ensure provider education efforts foster collaboration, shared accountability, and a culture of partnership across the network.

Value-Based Program Support
* Support Provider Engagement and Delegation Partnerships in the implementation and performance monitoring of value-based arrangements, including shared savings, risk-sharing, and quality incentive programs.
* Partner with provider engagement, delegation partnerships, clinical and population health teams to drive provider engagement in quality improvement and care coordination initiatives.

Team Leadership & Development
* Manage, mentor, and develop a team of provider relations account managers and representatives, setting clear goals and performance metrics aligned with organizational priorities.
* Foster a culture of continuous improvement, professional development, and high performance within the provider relations team.

Cross-Functional Collaboration
* Work closely with network contracting, credentialing, claims, IT, customer service, compliance, and quality teams to address provider needs and improve service delivery.
* Lead or support provider advisory councils and feedback mechanisms to integrate provider perspectives into strategic planning.
* Lead provider operations joint operating committee to ensure provider escalations and operational issues are addressed timely and effectively.
* Represent Provider Network in collaborative forums and committees, including payment policy and medical policy.

Other Duties
* Develop and maintain SOPs related to provider mailings, education and escalations support.
* Support departmental projects and initiatives as assigned.
* Represent the Provider Relations teams in cross-functional meetings and external stakeholder discussions.

Working Conditions:
* This is a remote or hyrbrid role with the expectation of working according to Commonwealth Care Alliance's standard operating hours of 8:30am-5pm Monday-Friday. Ability to travel to provider offices and access to reliable transportation.

Required Education (must have):
* Bachelor's degree in healthcare administration, business administration, public health, or a related field required.

Desired Education (nice to have):
* Master's degree in healthcare administration, business administration, public health, or a related field required.

Required Experience (must have):
* 8-10 years of progressively responsible experience in provider relations, network management, or healthcare operations within a managed care organization, health plan, or integrated delivery system.
* Demonstrated success building and managing provider partnerships across multiple provider types (e.g., primary care, specialty, behavioral health, hospitals, and community-based organizations).
* Proven ability to analyze provider performance metrics, identify improvement opportunities, and drive accountability to outcomes.
* Experience resolving escalated provider issues, collaborating cross-functionally to address root causes, and improving overall provider satisfaction.
* Track record of leading provider education and engagement initiatives, including provider communications, trainings, and forums.
* Demonstrated leadership and team management experience, with the ability to develop staff and lead through influence across departments.

Desired Experience (nice to have):
* Experience with dual-eligible (DSNP) populations preferred.
* 10+ years of experience in provider relations, contracting, or network operations, including 3-5 years in a director or senior management role.
* Experience with value-based payment models, performance-based contracting, or population health initiatives.
* Prior work with hospital systems, large medical groups, and specialty care networks.
* Experience supporting provider data integrity, onboarding, and credentialing processes.
* Proven success in network development or market expansion initiatives.

Required Knowledge, Skills & Abilities (must have):
* Strong understanding of claims processing, reimbursement methodologies, and payment policies, with the ability to interpret and communicate their impact on provider operations and satisfaction.
* Strong understanding of Medicare and Medicaid health plan operations, including regulatory and compliance requirements.
* Demonstrated analytical and data interpretation skills, with the ability to translate performance data into actionable strategies.
* Excellent communication and relationship management skills, with the ability to influence diverse internal and external stakeholders.
* Skilled in conflict resolution and issue escalation management, maintaining professionalism and diplomacy under pressure.
* Exceptional organizational, problem-solving, and project management abilities with a focus on results and accountability.
* Proficiency in Microsoft Office Suite (Excel, PowerPoint, Word) and comfort with data dashboards or reporting tools.
* Ability to lead and facilitate provider meetings, deliver presentations to executive audiences, and represent the organization at external events.
* Strong collaboration skills and the ability to work effectively across clinical, operational, contracting, and quality teams.
* Demonstrated professional presence and strategic thinking in a matrixed environment.
* Ability to manage multiple priorities, adapt to changing business needs, and maintain attention to detail in a fast-paced setting.
* Proactive in identifying issues and developing effective solutions.
* Adaptable and able to thrive in high-pressure environments, adjust to shifting priorities, and manage multiple deadlines.
* Results-oriented and self-motivated, with the ability to work independently and as part of a team to meet departmental goals.
* Demonstrates empathy, self-awareness, and the ability to navigate sensitive conversations diplomatically.

Required Language (must have):
* English

Desired Knowledge, Skills, Abilities & Language (nice to have):
* Experience developing and executing provider engagement strategies aligned with network performance goals.
* Familiarity with CRM systems (e.g., Salesforce) and provider relationship management tools.
* Understanding of claims operations, utilization management, and quality programs as they relate to provider satisfaction and network performance.
* Experience with change management and process improvement methodologies.
* Knowledge of healthcare economics, reimbursement structures, and financial performance metrics.
* Demonstrated commitment to equity, inclusion, and community partnership in provider engagement.
* Experience working cross-functionally with claims, finance, and contracting teams to address provider payment inquiries, resolve escalations, and implement process improvements related to reimbursement accuracy and timeliness.