Director, Provider Relations and Resolution Management

Job Summary

1 available position.

The Director, Provider Relations and Resolution Management strengthens the health and stability of long‑term partnerships across a defined portfolio of providers, including Provider Groups, Hospitals, Ancillary, SNFs, CalAIM entities, Direct Network organizations, and other strategically significant partners. The Director manages a team who are accountable for liaising between the health plan and its provider network, ensuring that providers receive timely issue resolution, and appropriate support in navigating health plan requirements, policies, programs, and operational processes.

This role transforms a traditionally reactive function into a proactive ecosystem that identifies friction points before they escalate, anchored by structured intake, root‑cause analysis, corrective action planning, and measurable service level agreements (SLAs). Through establishing high-performing provider relations organizations that supports tight collaboration with cross functional groups to reduce provider administrative burden, improves turnaround times, and ensures consistently smooth operational experience resulting in improved provider satisfaction, increased issue resolution and network stability. The position maintains alignment with Medi‑Cal, Medicare, DMHC, DHCS, CMS, and NCQA requirements and contributes directly to improved provider satisfaction and member outcomes.

Oversee operations, ensuring efficiency and effectiveness and is responsible for directing all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.

Duties

Leads all core provider‑facing interactions, ensuring providers receive reliable orientation, onboarding support, and ongoing education regarding policies, operational processes, and required tools. Through regular outreach and scheduled relationship check‑ins, helps providers navigate updates, policy changes, and administrative requirements.

In partnership with internal stakeholders, maintains active oversight of provider satisfaction levels, monitoring indicators such as dispute frequency, recurring operational challenges, and escalation patterns. When early signs of friction emerge, proactively intervenes often through structured provider forums or joint operational meetings to clarify concerns, offer guidance, and leverage network analytics to identify trends or opportunities for improvement.  Demonstrates this relationship model with providers to ensure a dependable point of contact for daily operations and reinforces the Health Plan’s commitment to service reliability and transparency.

Oversees the complete lifecycle of provider issues, starting with structured intake and moving through triage, investigation, remediation, final resolution, and post‑resolution validation. This responsibility includes designing an intake process that categorizes provider concerns based on financial impact, member implications, regulatory risk, and operational complexity.

Acts as the central orchestrator with cross‑functional teams to identify root causes and develop sustainable, system‑level solutions. Distinguishes isolated provider‑specific issues from broader operational deficiencies, ensuring corrective actions are documented thoroughly and communicated clearly to affected providers. Transparency throughout the resolution lifecycle is prioritized, with timely notifications and consistent status updates delivered to stakeholders.

Mentors and develops a high‑performance provider relations and resolution management team, fostering a culture centered on accountability, responsiveness, analytical rigor, and service excellence. Ensure team members are equipped to deliver consistent, scalable, and accurate support across varying provider segments, placing emphasis on proactive issue identification rather than reactive escalation management.

Develop goals, objectives and actions plans for assigned staff which includes full management responsibility for the hiring, performance reviews, salary reviews and disciplinary matters for direct reporting employees. Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals.

Manage department budgets and resources effectively.  Conduct strategic planning to utilize resources to meet current and future departmental and Enterprise-wide goals.

Lead discussions on policy operationalization and manages key policy perspective sharing.

Performs other duties as assigned

Duties Continued

Education Required

Education Preferred

Experience

Required:

At least 8 years of progressive experience across health plan, managed care, hospital, physician organization, IPA, or provider relations settings.

At least 6 years of experience leading staff, supervising and/or managing people.

At least 5 years of provider‑facing leadership will be evident through effective management of executive‑level relationships and the timely resolution of complex, multi‑dimensional issues.

Preferred:

Experience with Medi‑Cal, Medicare Advantage, and other government programs; familiarity with DMHC, DHCS, CMS, and NCQA requirements; and exposure to capitation and value‑based care, provider contracting, and hospital/health system partnerships

Skills

Required:

Deep understanding of managed care operations and delegated risk environments.

Demonstrated ability to build corrective action frameworks, optimize business processes, and deploy operational dashboards that translate claims, utilization, finance, and service data into action.

Expert written, verbal communication, presentation and negotiation skills

Ability to foster strong relationships with internal and external stakeholders.

Demonstrated ability to navigate complex environments and deliver results.

Demonstrated ability to think long-term and develop strategies that align with the overall goals of the organization.

Demonstrated ability to make sound and timely decisions.

Demonstrated ability to adapt to changing situations and adjust strategies accordingly.

Demonstrated ability to adapt to a fast-paced and evolving environment and to lead others through change.

Excellent interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment.

Demonstrated successful core leadership and relationship competencies.

Ability to exude executive presence, provider advocacy, and diplomacy.

Strong conflict resolution skills.

Preferred:

Adept at change management and cross‑functional leadership.

Strong analytical skills, including skills in root‑cause analysis, operational improvement, data interpretation, decision‑making, and SLA governance.

Bilingual in one of L.A. Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese   

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information

Required:
Travel to offsite locations for work required.