Executive Director-Provider Network Oversight

Location Address:

9521 San Mateo NE
Albuquerque, NM 87113-2237


Summary:

Presbyterian Healthcare Services (PHS) seeks a highly strategic and analytically driven executive to serve as Executive Director of Provider Network Oversight for Presbyterian Health Plan. This is a critical enterprise leadership role responsible for ensuring the integrity, compliance, and performance of the health plan’s provider network—spanning regulatory oversight, financial accuracy, vendor governance, and provider data excellence.

In an environment of increasing regulatory scrutiny and complexity across Medicare, Medicaid, and Commercial products, this leader will play a pivotal role in ensuring the organization meets and exceeds network adequacy, access, and transparency requirements while optimizing provider network performance and member experience.

With oversight of $4B+ in provider payments and $100M+ in vendor relationships, this role is uniquely positioned at the intersection of finance, provider strategy, operations, and compliance. The Executive Director will partner broadly across the organization to deliver best-in-class network oversight and enable strategic growth through data-driven insights and strong governance.

Work Arrangement:

• Remote: Open to applicants in the United States, excluding CA, IL, ND, NY, OH, WA, and WY.
• Hybrid: For individuals within 60 miles of Albuquerque, in-office presence is required Tuesday through Thursday.

Job Description:

Network Adequacy & Regulatory Leadership

• Define and lead enterprise network adequacy strategy, ensuring compliance with CMS, state Medicaid, Marketplace, and Department of Insurance requirements

• Oversee development, validation, and submission of regulatory filings, attestations, and audit responses across all lines of business

• Serve as senior liaison with regulators, ensuring transparency and alignment on provider access, directory accuracy, and compliance standards

• Ensure adherence to mental health parity and access requirements through partnership with network strategy teams

Provider Data Governance & Directory Excellence

• Establish enterprise provider data governance strategy to ensure accuracy, completeness, and consistency across systems

• Lead provider directory operations, including audits, correction workflows, and regulatory documentation

• Ensure compliance with CMS, NAIC, and state requirements for directory accuracy, timeliness, and transparency

• Partner with IT to enhance provider data systems, automation, and reporting capabilities

Vendor & Network Ecosystem Oversight

• Lead enterprise strategy, governance, and performance management for national, regional, and wrap provider networks

• Oversee vendor portfolio exceeding $100M annually, including contract performance, SLAs, and regulatory compliance

• Establish and monitor KPIs for vendor performance, ensuring timely remediation of deficiencies

• Ensure seamless integration of external networks into internal systems, reporting, and member-facing tools

Financial Integrity & Contract Conformance

• Oversee contract conformance monitoring and financial analysis of $4B+ in provider payments

• Partner with Medical Economics and Finance to ensure reimbursement accuracy and identify areas for improvement

• Develop reporting and auditing frameworks to ensure compliance with contractual terms and mitigate financial risk

Analytics, Reporting & Performance Management

• Establish network adequacy dashboards, KPIs, and reporting frameworks to identify access risks and network gaps

• Provide executive-level insights and recommendations to leadership and governance committees

• Lead performance review processes to drive accountability and continuous improvement

Leadership & Cross-Functional Collaboration

• Build and lead high-performing teams across provider data, network adequacy, and vendor oversight functions

• Foster strong collaboration across Finance, IT, Operations, Compliance, and Provider-facing teams

• Support enterprise initiatives related to product design, network expansion, and value-based care

Success Measures

Within the first 12–24 months, the Executive Director will:

• Ensure Regulatory Excellence: Achieve consistent compliance with all network adequacy and provider directory requirements across lines of business

• Strengthen Data Integrity: Improve provider data accuracy, completeness, and system integration across the enterprise

• Enhance Financial Oversight: Optimize contract conformance processes and identify opportunities to improve provider payment accuracy

• Elevate Vendor Performance: Strengthen governance and accountability across external network partners and delegated entities

• Advance Network Strategy: Deliver actionable insights that improve access, close network gaps, and support strategic growth

Additional Job Description:

Education

• Required: Bachelor’s degree in Healthcare Administration, Business Administration, Information Systems, Public Health, or related field

• Preferred: Master’s degree (MBA, MHA, or related discipline)

Knowledge & Work Experience

• Minimum of 10+ years of progressive experience in provider network management, provider data operations, regulatory reporting, or health plan compliance

• At least 5 years of senior leadership experience overseeing enterprise-level teams and vendor relationships

• Deep expertise in:

  • Network adequacy regulations (CMS, Medicaid, Marketplace)

  • Provider directory requirements and compliance standards

  • Healthcare finance and reimbursement

  • Contract conformance, audit processes, and internal controls

  • National and wrap network models and delegated arrangements

Core Competencies

• Regulatory Expert: Deep understanding of federal and state network adequacy and transparency requirements

• Financial & Analytical Strength: Ability to oversee large-scale financial operations and translate data into actionable insights

• Systems Thinker: Expertise in provider data ecosystems, technology integration, and process optimization

• Executive Communicator: Strong presence with the ability to engage regulators, vendors, and senior leadership

• Operational Leader: Proven ability to lead complex, cross-functional initiatives in matrixed environments

• Relationship Builder: Skilled at managing internal and external partnerships with influence and credibility

• Change Leader: Drives continuous improvement in highly regulated, evolving environments

Benefits
Benefits are effective day-one (for .45 FTE and above) and include:

• Competitive salaries
• Full medical, dental and vision insurance
• Flexible spending accounts (FSAs)
• Free wellness programs
• Paid time off (PTO)
• Retirement plans, including matching employer contributions
•  Continuing education and career development opportunities
• Life insurance and short/long term disability programs

About Us
Presbyterian Healthcare Services is a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, it is the state's largest private employer with approximately 11,000 employees.
 
Presbyterian's story is really the story of the remarkable people who have chosen to work here. Starting with Reverend Cooper who began our journey in 1908, the hard work of thousands of physicians, employees, board members, and other volunteers brought Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system, serving more than 700,000 New Mexicans.
 
We are part of New Mexico's history - and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.

About New Mexico
New Mexico's unique blend of Spanish, Mexican and Native American influences contribute to a culturally rich lifestyle. Add in Albuquerque's International Balloon Fiesta, Los Alamos' nuclear scientists, Roswell's visitors from outer space, and Santa Fe's artists, and you get an eclectic mix of people, places and experiences that make this state great.
 
Cities in New Mexico are continually ranked among the nation's best places to work and live by Forbes magazine, Kiplinger's Personal Finance, and other corporate and government relocation managers like Worldwide ERC.
 
New Mexico offers endless recreational opportunities to explore, and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.
 
AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.