Director, Provider Relations

011230 CA-Provider Engagement & Performance Position Summary: The Director of Provider Relations leads the strategic vision and operational execution of provider relations for Commonwealth Care Allianceu2019s 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: u2022 Yes, this position does have direct reports including Provider Relations Account Managers. Essential Duties & Responsibilities: Provider Relationship Management u2022 Develop and execute the organizationu2019s provider relations strategy, ensuring strong, collaborative partnerships with hospitals, physician groups, LTSS, HCBS, behavioral health, and ancillary providers. u2022 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. u2022 Lead ongoing communication efforts, working closely with Provider Communications Manager, to keep providers informed of organizational objectives, regulatory updates, operational changes, and compliance requirements. u2022 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 u2022 Collaborate with contracting, operations, and analytics teams to monitor network performance against internal and regulatory benchmarks. u2022 Ensure provider network compliance with CMS, state Medicaid agency, and NCQA standards. u2022 Lead initiatives to streamline provider operations, reduce administrative burden, and improve the overall provider experience. u2022 Analyze trends in provider inquiries and grievances to identify root causes, recommend process improvements, and enhance provider satisfaction and performance. u2022 Partner with senior leaders to communicate resolution and outcomes and drive cross-functional accountability for systemic improvements. u2022 Ensure all issue resolution processes align with regulatory requirements and organizational standards for service quality and responsiveness. Provider education u2022 Collaborate with Provider Communications, Provider Engagement and Delegation in the development and execution of a comprehensive provider education strategy. u2022 Oversee the design and delivery of high-impact training programs, webinars, and materials that strengthen provider understanding of CCAu2019s model of care, operations, and compliance standards. u2022 Partner with internal stakeholders to ensure educational initiatives support system-wide consistency and continuous improvement. u2022 Leverage data and provider feedback to identify educational needs, measure effectiveness, and adapt programs for maximum impact. u2022 Represent CCA as a thought leader in provider education at meetings, forums, and partnerships. u2022 Ensure provider education efforts foster collaboration, shared accountability, and a culture of partnership across the network. Value-Based Program Support u2022 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. u2022 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 u2022 Manage, mentor, and develop a team of provider relations account managers and representatives, setting clear goals and performance metrics aligned with organizational priorities. u2022 Foster a culture of continuous improvement, professional development, and high performance within the provider relations team. Cross-Functional Collaboration u2022 Work closely with network contracting, credentialing, claims, IT, customer service, compliance, and quality teams to address provider needs and improve service delivery. u2022 Lead or support provider advisory councils and feedback mechanisms to integrate provider perspectives into strategic planning. u2022 Lead provider operations joint operating committee to ensure provider escalations and operational issues are addressed timely and effectively. u2022 Represent Provider Network in collaborative forums and committees, including payment policy and medical policy. Other Duties u2022 Develop and maintain SOPs related to provider mailings, education and escalations support. u2022 Support departmental projects and initiatives as assigned. u2022 Represent the Provider Relations teams in cross-functional meetings and external stakeholder discussions. Working Conditions: u2022 This is a remote or hyrbrid role with the expectation of working according to Commonwealth Care Allianceu2019s standard operating hours of 8:30am-5pm Monday-Friday. Ability to travel to provider offices and access to reliable transportation. Required Education (must have): u2022 Bacheloru2019s degree in healthcare administration, business administration, public health, or a related field required. Desired Education (nice to have): u2022 Masteru2019s degree in healthcare administration, business administration, public health, or a related field required. Required Experience (must have): u2022 8u201310 years of progressively responsible experience in provider relations, network management, or healthcare operations within a managed care organization, health plan, or integrated delivery system. u2022 Demonstrated success building and managing provider partnerships across multiple provider types (e.g., primary care, specialty, behavioral health, hospitals, and community-based organizations). u2022 Proven ability to analyze provider performance metrics, identify improvement opportunities, and drive accountability to outcomes. u2022 Experience resolving escalated provider issues, collaborating cross-functionally to address root causes, and improving overall provider satisfaction. u2022 Track record of leading provider education and engagement initiatives, including provider communications, trainings, and forums. u2022 Demonstrated leadership and team management experience, with the ability to develop staff and lead through influence across departments. Desired Experience (nice to have): u2022 Experience with dual-eligible (DSNP) populations preferred. u2022 10+ years of experience in provider relations, contracting, or network operations, including 3u20135 years in a director or senior management role. u2022 Experience with value-based payment models, performance-based contracting, or population health initiatives. u2022 Prior work with hospital systems, large medical groups, and specialty care networks. u2022 Experience supporting provider data integrity, onboarding, and credentialing processes. u2022 Proven success in network development or market expansion initiatives. Required Knowledge, Skills & Abilities (must have): u2022 Strong understanding of claims processing, reimbursement methodologies, and payment policies, with the ability to interpret and communicate their impact on provider operations and satisfaction. u2022 Strong understanding of Medicare and Medicaid health plan operations, including regulatory and compliance requirements. u2022 Demonstrated analytical and data interpretation skills, with the ability to translate performance data into actionable strategies. u2022 Excellent communication and relationship management skills, with the ability to influence diverse internal and external stakeholders. u2022 Skilled in conflict resolution and issue escalation management, maintaining professionalism and diplomacy under pressure. u2022 Exceptional organizational, problem-solving, and project management abilities with a focus on results and accountability. u2022 Proficiency in Microsoft Office Suite (Excel, PowerPoint, Word) and comfort with data dashboards or reporting tools. u2022 Ability to lead and facilitate provider meetings, deliver presentations to executive audiences, and represent the organization at external events. u2022 Strong collaboration skills and the ability to work effectively across clinical, operational, contracting, and quality teams. u2022 Demonstrated professional presence and strategic thinking in a matrixed environment. u2022 Ability to manage multiple priorities, adapt to changing business needs, and maintain attention to detail in a fast-paced setting. u2022 Proactive in identifying issues and developing effective solutions. u2022 Adaptable and able to thrive in high-pressure environments, adjust to shifting priorities, and manage multiple deadlines. u2022 Results-oriented and self-motivated, with the ability to work independently and as part of a team to meet departmental goals. u2022 Demonstrates empathy, self-awareness, and the ability to navigate sensitive conversations diplomatically. Required Language (must have): u2022 English Desired Knowledge, Skills, Abilities & Language (nice to have): u2022 Experience developing and executing provider engagement strategies aligned with network performance goals. u2022 Familiarity with CRM systems (e.g., Salesforce) and provider relationship management tools. u2022 Understanding of claims operations, utilization management, and quality programs as they relate to provider satisfaction and network performance. u2022 Experience with change management and process improvement methodologies. u2022 Knowledge of healthcare economics, reimbursement structures, and financial performance metrics. u2022 Demonstrated commitment to equity, inclusion, and community partnership in provider engagement. u2022 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. Compensation Range/Target: $133,600 - $200,400 Commonwealth Care Alliance takes into consideration a combination of a candidateu2019s education, training, and experience as well as the positionu2019s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employeeu2019s total well-being and offer a substantial and comprehensive total rewards package.EEO is The Law Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.

Created: 2025-12-05