Manager - Network Quality and Management

*** Candidates must live in NJ, NYC or Philly are for consideration*** Manager, Network Quality & Management 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 Manager's guidance. This position leverages clinical expertise to oversee quality initiatives, establish clinical performance benchmarks, 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 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 34 Develop and implement quality standards and network management strategies that drive clinician engagement, network growth, and retention across current and prospective service areas34 Build and maintain trust-based relationships with clinicians, clinical leaders, and healthcare providers; serve as a liaison to understand practice patterns, clinical concerns, and needs34 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 offerings34 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 indicators34 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)34 Lead and facilitate clinical meetings with providers, medical groups, clinical advisory committees, and regulatory representatives using clinical knowledge to drive discussions34 Attend key provider conferences and advisory committees to demonstrate leadership and subject matter expertise34 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 34 Manage, mentor, and coach direct reports including clinical and administrative staff; provide clinical oversight and guidance to non-clinical provider relations associates34 Establish and monitor performance expectations, development plans, and career pathways34 Conduct team audits and monitoring activities to ensure quality standards34 Provide coaching and guidance to customer service teams to improve provider experience34 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 forums34 Drive collaboration across provider relations, network contracting, and quality Operational Management & Compliance 34 Provide oversight of provider complaint resolution processes; escalate clinical issues and quality concerns to appropriate resolution, with operational management delegated to provider relations team34 Solves operational challenges34 Conduct regular reviews and audits of the provider network to ensure compliance with client and regulatory requirements34 Manage regulatory reports and partner with technical and functional teams to compile and audit compliance documentation34 Coordinate with bill review, credentialing, and other departments to address provider service issues34 Maintain accurate and up-to-date provider data in organizational systems34 Serve as subject matter expert regarding contract obligations relating to network adequacy and provider agreements Strategic Initiatives & Communications 34 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 team34 Monitor network adequacy through geo-access analysis and partner with network teams to identify and fill gaps34 Support adoption of enterprise tools that reduce administrative burden and improve provider experience34 Provide recommendations based on analysis of network performance data and provider feedback34 Facilitate communication between healthcare providers and the organization, including training on policies and procedures Required Qualifications 34 Bachelor's degree required or BA, BSN, or Current RN licensure in New Jersey, or Family Nurse Practitioner (FNP) / Acute Care Nurse Practitioner (ACNP) license/certification34 6+ years of provider relations or clinical nursing experience in direct patient care or clinical leadership roles34 3+ years of team leadership, clinical management, or quality improvement experience within a healthcare setting34 Proven ability to establish and monitor key performance indicators34 Proven ability to meet deadlines and manage competing priorities34 Proven ability to influence course of action and build consensus across teams34 Intermediate proficiency with Microsoft Word, Excel, and PowerPoint34 Excellent organizational and project management skills34 Strong verbal and written communication abilities Preferred Qualifications 34 Master of Science in Nursing (MSN), MBA, or Master of Health Administration (MHA)34 Experience with compliance audits and regulatory oversight34 Experience analyzing and interpreting complex healthcare data34 Demonstrated experience managing staff in a healthcare setting34 Experience with healthcare IT systems and tools (claims systems, provider portals, etc.)34 Experience with program management within a health plan or provider organization34 Knowledge of clinical credentialing, privileging, and peer review processes34 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.