Design and lead the enterprise care routing strategy, aligning provider selection and referral pathways with organizational goals for quality, affordability, access, and member experience.
Define and maintain preferred network frameworks that segment providers based on performance, capacity, access, and clinical outcomes.
Establish clear, data-driven criteria for identifying high-performing providers while ensuring adequate access for members across geographies and specialties.
Own the development of network intelligence capabilities that integrate claims, utilization, clinical outcomes, access, and member demand data.
Evaluate network adequacy beyond regulatory compliance measures, assessing whether the network meaningfully meets member needs related to access, capacity, timeliness, specialty coverage, and care continuity.
Identify gaps, redundancies, or misalignments in the network that may impact care routing effectiveness or member experience.
Provide data-driven recommendations to adjust network composition, provider mix, or geographic coverage based on performance and access insights.
Design and embed care routing workflows within existing operational teams (e.g., UM, Care Management, Member Services, Provider Relations, Scheduling) to steer members to preferred providers while preserving access and choice.
Build, lead, and develop a small, high-performing team focused on network intelligence, care routing execution, and network adequacy analysis.

Requirements

10+ years of experience in healthcare network management, clinical operations, access strategy, or value-based care environments.
5+ years of leadership experience managing teams or enterprise-level initiatives.
Demonstrated experience evaluating network adequacy, access, or provider capacity beyond regulatory compliance requirements.
Strong understanding of provider performance measurement, referral patterns, access standards, and utilization management.
Proven ability to translate data insights into operational workflows that influence care delivery and member access.
Experience operating effectively in complex, matrixed organizations.
Bachelor’s degree required in Healthcare Administration, Public Health, Business Administration, Nursing, or a related field.
Master’s degree preferred (e.g., MHA, MPH, MBA, MSN).
Preferred: Lean Six Sigma Black; PMP or Agile certification.
Required: Deep understanding of healthcare provider networks, network adequacy, access standards, and care delivery models.
Strong analytical skills with the ability to synthesize access, utilization, and performance data into actionable strategies.
Ability to balance member access, provider performance, and operational feasibility in care routing decisions.
Strong communication and executive presence, with the ability to influence clinical, operational, and network stakeholders.
Experience designing and operationalizing workflows across clinical and non-clinical teams.

Benefits

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Applicant Tracking System Keywords

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Hard Skills & Tools

network managementclinical operationsaccess strategyvalue-based careprovider performance measurementutilization managementdata analysisworkflow designnetwork adequacy evaluationcare delivery models

Soft Skills

leadershipanalytical skillscommunicationinfluenceteam developmentoperational feasibilitystrategic thinkingproblem-solvingcollaborationexecutive presence

Certifications

Lean Six Sigma BlackPMPAgile