Head of Provider Operations, TRICARE Oversees Program

Essential Job Duties and Responsibilities:

The Head of Provider Operations leads the operational delivery and performance of provider-facing and provider-enabling services for TOP. This role is accountable for day-to-day execution, controls, and continuous improvement across Claims operations (including governance of the WPS vendor and internal claims team coordination), credentialing and provider data integrity (NSS), and provider support services (TPSS).

The role builds and enforces operational KPI frameworks (where gaps exist), establishes disciplined performance management cadences, and ensures audit readiness through robust process controls, documentation completeness, and data quality. The Head of Provider Operations works in close partnership with the Provider Network Director and PNMs to reduce friction for providers, improve right-first-time outcomes, and meet contractual obligations and measurable outcomes.

Key Responsibilities 

Operational Leadership & Delivery Excellence
•    Define and maintain an effective operational structure for provider operations (Claims, NSS, TPSS), including roles, span of control, escalation pathways, and coverage plans.
•    Lead managers to deliver consistent operational execution, quality, and productivity across regions and time zones.
•    Establish standard work, capacity planning, and workload management to stabilize performance and reduce variability.

Claims Operations Leadership & Vendor Governance (WPS)
•    Own operational management of the Claims vendor (WPS): governance cadence, SLAs/KPIs, issue management, root-cause elimination, and continuous improvement plans.
•    Coordinate the internal Claims operational team interface with WPS to ensure clear handoffs, accountability, and timely resolution of systemic issues.
•    Operate escalation pathways for complex claims/billing issues and ensure appropriate routing for suspected fraud-related pathways in line with program requirements. 
•    Partner with Provider Network Director/PNMs and TPSS to improve upstream provider education and data quality that supports timely, accurate claim processing. 
•    Own on-time and in-full claims reimbursement to providers, deep dive reasons for deviations, and implement countermeasures to comply with KPI targets.

Credentialing Operations & Provider Data Integrity (NSS)
•    Own credentialing throughput and quality performance: document validation, accreditation tracking, and provider profile integrity (e.g., SPIN data maintenance) aligned to applicable standards. 
•    Standardize credentialing controls and data governance to improve completeness and reduce rework; ensure sustained audit readiness. 
•    Implement quality assurance and corrective-action routines to address recurring defects and prevent downstream operational failures. 

Provider Support Services (TPSS) Delivery
•    Ensure TPSS delivers efficient provider support, education, and claims-related service to providers/beneficiaries, including clear escalation processes for billing/claims support issues. 
•    Standardize provider communications and service standards to improve provider experience and reduce preventable escalations. 
•    Drive proactive provider education to improve “clean submission” behavior and reduce claim friction and avoidable rework. 

KPI System Build, Performance Management & Continuous Improvement
•    Translate operational priorities into measurable KPIs (build where absent), define measurement logic, set targets, and cascade accountability across Claims/NSS/TPSS. 
•    Establish dashboards and operational review cadence (daily/weekly/monthly/quarterly) to drive corrective actions and continuous improvement. 
•    Improve cost, quality, access enablement, and “Right First Time” execution by reducing rework and preventable escalations through upstream fixes and better provider support. 

Controls, Compliance & Audit Readiness (Execution Owner)
•    Own readiness for audits and formal reviews by ensuring controls, documentation completeness, and data integrity are consistently met; escalate risks early with clear mitigation plans.
•    Maintain end-to-end operational process documentation and clear decision rights/hand-offs in partnership with Provider Network Director governance (PACE/RACI alignment).

Description:

Required Skills and Knowledge (Brief description of technical knowledge or skills needed to perform the job)
•    Strong understanding of provider operations: credentialing controls, data governance, audit readiness, provider support services, and claims operational interfaces. 
•    Deep expertise in medical and healthcare claims processing, supported by hands-on, transferable experience in shaping and governing payment policy.
•    Demonstrated operational excellence capability: process standardization, KPI management, and continuous improvement. 
•    Vendor management expertise (governance model, SLA/KPI frameworks, performance improvement, escalation management).
•    Strong analytical skills; ability to interpret performance data and drive data-driven decisions at pace.
•    Proven leadership in matrix environments; ability to influence cross-functional stakeholders and sustain change. 
•    Excellent communication skills; able to lead difficult conversations with internal leaders, vendors, and providers. 

Required Competencies (Critical behaviors necessary to successfully perform the job)

Strategic Leadership & Decision-Making
•    Provides clear direction and sets high standards for global network operations performance.
•    Makes prompt, confident decisions under ambiguity, balancing medical priorities with operational feasibility.

Delivering Results & Meeting Customer Expectations
•    Maintains relentless focus on contractual KPIs, access-to-care standards, and readiness objectives.
•    Monitors and enforces quality and productivity across dispersed teams; drives continuous improvement.

Collaboration, Influencing & Negotiation
•    Builds strong relationships with medical leadership, PNMs, and cross‑functional partners. 
•    Gains commitment through persuasion and negotiation; secures alignment among diverse stakeholders.
•    Leads difficult conversations with confidence and diplomacy—resolving conflicts, addressing performance gaps, and managing provider or client escalations effectively.

Analytical & Systems Thinking
•    Interprets operational and clinical data to identify patterns, root causes, and improvement opportunities.
•    Connects tactical issues to strategic objectives; designs scalable solutions for global deployment.

Change Leadership & Coaching
•    Acts as a change agent during network transformation; communicates vision and milestones effectively.
•    Coaches leaders on provider engagement, lifecycle governance, and readiness enablement

Resilience & Adaptability
•    Performs effectively under pressure and during disruption; maintains composure and focus on mission-critical outcomes.

Communication & Presentation Excellence
•    Articulates complex strategies in clear, compelling language for executive, clinical, and operational audiences.
•    Delivers impactful presentations and reports that drive alignment and accountability.

Required Work Experience (Brief description of the job-related experience needed to perform the job)
•    Strong understanding of provider operations: credentialing controls, data governance, audit readiness, provider support services, and claims operational interfaces. 
•    Demonstrated operational excellence capability: process standardization, KPI management, and continuous improvement. 
•    Vendor management expertise (governance model, SLA/KPI frameworks, performance improvement, escalation management).
•    Strong analytical skills; ability to interpret performance data and drive data-driven decisions at pace. 
•    Proven leadership in matrix environments; ability to influence cross-functional stakeholders and sustain change. 
•    Excellent communication skills; able to lead difficult conversations with internal leaders, vendors, and providers. 

Required Qualifications (Brief description of the educational background needed to perform the job)

Education
•    Bachelor's degree in business, Healthcare Management, Operations, or related field. Master’s degree or equivalent qualification is strongly preferred.

Required Languages (Brief description of the language skills needed to perform the job)
•    Excellent English language skills (verbal and written)
•    Other languages are a plus (German, Italian, Korean, Japanese)

Travel / Rotation Requirements (Brief description of any travel or rotation requirements)
•    Travel up to 40% of the time