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 expert