Manager, Network Quality & Management

Position Summary

The Manager of Network Quality & Management leads a dedicated team responsible for establishing and maintaining relationships with clinicians, hospitals, and healthcare providers while ensuring clinical quality standards, regulatory compliance, and continuous performance improvement across the provider network. The clinical strategy and oversight are provided by the Manager, who serves as a clinical leader and strategic advisor. Routine provider relations and operational tasks are executed by non-clinical provider relations associates under the Director's clinical guidance. This position leverages clinical expertise to oversee quality initiatives, establish clinical performance benchmarks, credential clinical providers, and guide both clinical and administrative staff to achieve high standards of clinical care and network performance.

This is a fast-paced, multifaceted role requiring clinical judgment, strong communication with clinicians, and the ability to manage competing priorities across quality improvement, network development, and regulatory compliance. The Manager will spend significant time building trust-based relationships with clinicians and clinical leaders directly, both virtually and in person, while leveraging clinical expertise, quality data, and performance analytics to identify opportunities for clinical excellence, network expansion, and strategic partnerships.

Reports to: VP of Network Management and Strategy

Primary Responsibilities

Clinical Network Development & Quality Management

• Develop and implement quality standards and network management strategies that drive clinician engagement, network growth, and retention across current and prospective service areas
• Build and maintain trust-based relationships with clinicians, clinical leaders, and healthcare providers; serve as a liaison to understand practice patterns, clinical concerns, and needs
• Partner with clinicians and clinical leaders to establish clinical quality improvement initiatives, benchmark clinical performance against best practices and standards, and identify gaps in clinical capabilities or service offerings
• Conduct regular onsite clinical assessments with providers, utilizing clinical expertise and performance data to determine priority visits based on quality metrics, clinical outcomes, utilization patterns, member experience, and regulatory compliance indicators
• Represent the organization as a clinical subject matter expert in provider meetings, regulatory forums, clinical conferences, and key healthcare events; position the organization for network expansion into new service areas and states (minimum 25% travel)
• Lead and facilitate clinical meetings with providers, medical groups, clinical advisory committees, and regulatory representatives using clinical knowledge to drive discussions
• Attend key provider conferences and advisory committees to demonstrate leadership and subject matter expertise
• Monitor and drive improvement in clinical quality metrics, clinical outcomes, and clinician satisfaction across the network; establish clinical performance dashboards and quality benchmarks aligned with industry standards and regulatory requirements

Team Leadership & Development

• Manage, mentor, and coach direct reports including clinical and administrative staff; provide clinical oversight and guidance to non-clinical provider relations associates
• Establish and monitor performance expectations, development plans, and career pathways
• Conduct team audits and monitoring activities to ensure quality standards
• Provide coaching and guidance to customer service teams to improve provider experience
• Oversee team operations and delegate routine provider relations activities to non-clinical associates while maintaining direct engagement in clinical quality assessments, clinician relationship building, and clinical leadership forums
• Drive collaboration across provider relations, network contracting, and quality

Operational Management & Compliance

• Provide oversight of provider complaint resolution processes; escalate clinical issues and quality concerns to appropriate resolution, with operational management delegated to provider relations team
• Solves operational challenges
• Conduct regular reviews and audits of the provider network to ensure compliance with client and regulatory requirements
• Manage regulatory reports and partner with technical and functional teams to compile and audit compliance documentation
• Coordinate with bill review, credentialing, and other departments to address provider service issues
• Maintain accurate and up-to-date provider data in organizational systems
• Serve as subject matter expert regarding contract obligations relating to network adequacy and provider agreements

Strategic Initiatives & Communications

• Provide strategic oversight and content guidance for provider communications including annual provider manual updates, newsletters, and provider resources; delegate content development and distribution to provider relations team
• Monitor network adequacy through geo-access analysis and partner with network teams to identify and fill gaps
• Support adoption of enterprise tools that reduce administrative burden and improve provider experience
• Provide recommendations based on analysis of network performance data and provider feedback
• Facilitate communication between healthcare providers and the organization, including training on policies and procedures

Required Qualifications

• BA, BSN, or Current RN licensure in New Jersey, or Family Nurse Practitioner (FNP) / Acute Care Nurse Practitioner (ACNP) license/certification
• 6+ years of provider relations or clinical nursing experience in direct patient care or clinical leadership roles
• 3+ years of team leadership, clinical management, or quality improvement experience within a healthcare setting
• Proven ability to establish and monitor key performance indicators
• Proven ability to meet deadlines and manage competing priorities
• Proven ability to influence course of action and build consensus across teams
• Intermediate proficiency with Microsoft Word, Excel, and PowerPoint
• Excellent organizational and project management skills
• Strong verbal and written communication abilities

Preferred Qualifications

• Master of Science in Nursing (MSN), MBA, or Master of Health Administration (MHA)
• Experience with compliance audits and regulatory oversight
• Experience analyzing and interpreting complex healthcare data
• Demonstrated experience managing staff in a healthcare setting
• Experience with healthcare IT systems and tools (claims systems, provider portals, etc.)
• Experience with program management within a health plan or provider organization
• Knowledge of clinical credentialing, privileging, and peer review processes
• Experience with multi-state network development, regulatory environments, or health plan expansion initiatives

Work Environment & Location

This position offers remote work flexibility while requiring travel within the service area as needed (minimum 25% travel expected for provider meetings and in-person visits). The role operates in a fast-paced, dynamic environment requiring strong attention to detail and excellent multitasking abilities.