Note: The job is a remote job and is open to candidates in USA. Clover Health is a Medicare Advantage plan focused on improving member health through technology and data-driven insights. The Director of Network Operations will lead the provider data ecosystem, credentialing frameworks, and network adequacy models, ensuring data integrity and regulatory compliance. This role involves managing remote teams, overseeing third-party vendors, and integrating AI technologies to optimize provider data management and network operations.
Responsibilities
- Hold accountability for the accuracy, regulatory compliance (CMS), and publication of the consumer-facing Provider Directory, implementing strict controls to minimize data discrepancies
- Serve as the end-to-end owner of the PDM Platform. Champion the data architecture strategies required to ingest diverse API feeds (NPPES, CAQH, provider rosters, webscraping) into our data warehouse, applying weighted scoring and business rules to build a high-fidelity provider data environment
- Partner closely with the Chief Medical Officer (CMO), who chairs the committee, to own the end-to-end business operations of the enterprise Credentialing Committee. You will ensure monthly meetings are executed seamlessly and that our third-party credentialing vendor arrives fully prepared with all necessary cases, files, and documentation for review in compliance with NCQA and regulatory standards
- Act as the primary lead for the strategic oversight of our third-party credentialing partners and BPaaS operational vendors. Establish rigorous data-driven performance metrics, hold partners to high operational standards, and seamlessly synchronize external workflows with internal goals
- Spearhead the integration of advanced AI and Large Language Models (LLMs) to automate manual provider data updates, optimize validation pipelines, and proactively identify directory inaccuracies
- Directly manage, mentor, and scale a highly skilled, fully remote network operations team, fostering an inclusive culture centered on accountability, technological fluency, and precision
- Provide the overarching strategic vision for network operations. Act as an executive unblocker, driving rapid, successful resolution to open, complex projects across Clinical, Claims, Product, Compliance, and Configuration teams
Skills
- 8+ years of executive leadership experience within healthcare network operations, provider data management, or credentialing, with a heavy emphasis on Medicare Advantage
- Deep Subject Matter Expert in Provider Data Management (PDM), with a proven track record of transforming complex data infrastructures into highly efficient, automated systems
- Sophisticated understanding of CMS network adequacy regulations, provider directory compliance mandates, and NCQA credentialing standards
- Extensive experience managing and holding 3rd party credentialing vendors and BPaaS partners to strict performance and service level standards
- Exceptionally AI- and data-forward—passionate about deploying LLMs (Claude, Gemini, ChatGPT) and advanced technical solutions to replace manual workflows
- Experience or conceptual mastery around building a PDM 'Golden Record'—architecting automated data pipelines that ingest fragmented inputs (NPPES, CAQH, rosters, webscraping) into a data warehouse and applying algorithmic weighted averages to triangulate the true source-of-truth
- Proven track record of successfully managing, scaling, and maintaining culture within fully remote teams
- Master of cross-functional influence, capable of stepping into complex, multi-departmental environments to realign priorities and push stalled initiatives across the finish line
- Data-focused leader who builds strategy based on sophisticated dashboards and trend analysis
Benefits
- Competitive base salary and equity opportunities
- Performance-based bonus program
- 401k matching
- Regular compensation reviews to recognize and reward exceptional contributions
- Comprehensive medical, dental, and vision coverage
- No-Meeting Fridays
- Monthly company holidays
- Access to mental health resources
- Generous flexible time-off policy
- Remote-first culture that supports collaboration and flexibility
- Learning programs
- Mentorship
- Professional development funding
- Regular performance feedback and reviews
- Employee Stock Purchase Plan (ESPP) offering discounted equity opportunities
- Reimbursement for office setup expenses
- Monthly cell phone & internet stipend
- Remote-first culture, enabling collaboration with global teams
- Paid parental leave for all new parents
Company Overview