Network Quality Manager

Who We Are

We’re a group of talented, driven professionals who strive every day to improve the lives of our clients, our providers and the ultimate stakeholders – the injured workers. We offer an exciting workplace environment plus competitive salaries and benefits. What makes us stand out? It’s the people, the culture we foster and the opportunity to learn and to grow.]

Job Summary

We are seeking a strategic, analytical Risk Manager to oversee and optimize provider network performance with a strong emphasis on dispute avoidance, dispute resolution, and risk mitigation within the workers’ compensation bill review process.

In this role, you will act as the central point of accountability for provider reimbursement disputes, ensuring network partners operate in alignment with contractual, regulatory, and operational expectations. You will collaborate closely with internal stakeholders, provider networks, and clients to reduce dispute volume, improve resolution outcomes, and protect financial and reputational risk while maintaining high service quality.

Primary Duties & Responsibilities

Dispute Prevention & Resolution

• Develop and enforce network policies and workflows to provider reimbursement disputes related to PPO discounts, provider contracts, and post-bill review reductions.
• Analyze provider appeals and adjustments to identify trends and root causes, recommending data-driven improvements.
• Collaborate with legal, clinical, and compliance teams to resolve provider disputes efficiently and consistently.
• Promote proactive communication with providers to enhance understanding of reimbursement processes and reduce conflict.

Performance Measurement & Optimization

• Design and maintain network performance dashboards tracking metrics.
• Collaborate with analytics teams to evaluate network quality, effectiveness, and impact on claims outcomes.

Product Development & Enhancement

• Own the lifecycle of network-related solutions that enhance compliance, savings, and stakeholder satisfaction.
• Translate client requirements and regulatory changes into actionable product improvements.
• Monitor market and regulatory trends to guide product innovation and maintain competitive advantage.

Cross-Functional Leadership & Collaboration

• Serve as the subject matter expert on network products, provider performance, and dispute processes.
• Partner with internal teams—including sales, account management, RFPs, and product launches.
• Collaborate with external vendors and partners

Qualifications

• 7-10 years of experience in Network Management and or Group Health?
• Experience working in or with Bill Review disciplines
• Strong written and verbal communications
• Experience working in a matrixed organization and effective with multi-stakeholder management
• Excellent relationship management and issue resolution skills
• Enjoys managing talent at all levels; familiarity working with offshore teams a plus
• Proven experience in vendor management 
• Excellent organizational, analytical, and communication skills.

Working Conditions & Physical Requirements

• The work environment characteristics described here is representative of those of a standard office setting. The noise level in the work environment is usually moderate. 

• The work environment characteristics described here is representative of those of a standard office setting. The noise level in the work environment is usually moderate. 

• While performing the duties of this job, the employee must be able to remain in a stationary position over 50% of the work day; move about inside the office to access files or office equipment; use hands to finger, handle, or feel objects, tools, or controls to operate a computer and other office productivity machines; reach with hands and arms; must communicate and converse with co-workers; and detect/discern information accurately. Specific vision abilities required by this job include close vision and the ability to adjust focus. The employee must occasionally lift and/or move up to 10 pounds.

• While performing the duties of this job, the employee must be able to remain in a stationary position over 50% of the work day; move about inside the office to access files or office equipment; use hands to finger, handle, or feel objects, tools, or controls to operate a computer and other office productivity machines; reach with hands and arms; must communicate and converse with co-workers; and detect/discern information accurately. Specific vision abilities required by this job include close vision and the ability to adjust focus. The employee must occasionally lift and/or move up to 10 pounds.