Director of Managed Care

RediMinds, Inc•Southfield, MI

About The Position

The Director of Managed Care will build RediMinds’ managed care division from the ground up, including Utilization Review (UR), Medical Bill Review (MBR), Nurse Case Management (NCM), and Provider Networks (HCO/MPN). The Director sets strategy, sequences the launch of each service line, builds the team and infrastructure, and wins the first clients. The role is accountable for creating an integrated, compliant, and profitable managed care business. The Director will develop the division’s strategy and phased launch plans; establish service models, pricing, quality standards, and revenue targets; and build business development and go-to-market capabilities. The role will design and launch each service line, develop compliance and operational infrastructure, select systems and vendor partners, recruit and lead staff, manage client relationships, and oversee budgets, P&L, and the path to profitability. The Director reports to the Chief Operating Officer and works closely with executive leadership and cross-functional teams.

Responsibilities

Develop the strategy, business plan, and phased roadmap for launching Utilization Review, Medical Bill Review, Nurse Case Management, and Provider Networks.
Determine launch sequencing, resource requirements, and build-versus-partner decisions for each service line.
Define service models, pricing, quality standards, revenue targets, milestones, and success metrics, and report progress to executive leadership.
Build the sales strategy and go-to-market approach, including integrated and bundled service offerings.
Identify and close initial clients among employers, insurers, third-party administrators, and self-insured entities.
Develop the sales pipeline and materials, including proposals, RFP responses, pricing models, and contract negotiations.
Establish a framework for demonstrating outcomes and ROI as data becomes available, and represent the company at industry events and client and prospect meetings.
Design the Utilization Review program, including policies, procedures, California-required UR plan documentation, decision standards, evidence-based guidelines, turnaround benchmarks, and documentation requirements.
Participate in URAC accreditation efforts; recruit clinical reviewers and physician advisors; and build quality oversight and audit readiness.
Design the Medical Bill Review program, including fee schedule application, coding review, and appeals or dispute processes; select and implement technology or vendor partners; and establish performance benchmarks and client reporting.
Design the Nurse Case Management program, including standards, caseload guidelines, pricing, and clinical quality oversight; recruit and onboard licensed clinical staff; and define outcome metrics.
Lead HCO certification and MPN approval strategy, including regulatory applications and supporting documentation.
Build provider networks through recruitment, credentialing, contracting, and adequacy across required specialties and geographies; establish provider data management and regulatory filing processes.
Design compliance frameworks, policies, controls, monitoring, reporting, and audit-readiness processes for all service lines, track regulatory changes, and communicate material risks and recommended actions to executive leadership.
Design client onboarding across service lines, serve as senior contact for early clients, set service expectations, lead account reviews, and identify opportunities to expand services.
Define the organizational structure and staffing plan; recruit, hire, and develop managers and staff; set performance and accountability expectations; and phase hiring to match client growth and revenue.
Select and implement platforms across service lines, design standardized workflows, quality controls, client-facing reporting, and analytics, and partner with IT and external vendors on implementation.
Build and manage the division’s startup budget, staffing plan, and vendor spend; own P&L accountability as services launch and scale; and define the path to profitability.
Assess the financial implications of service models, pricing, and investments, and make recommendations to executive leadership.
Partner with the COO and executive team on growth, risk, and market positioning; collaborate with compliance, finance, technology, and client services; and identify market trends, emerging risks, and investment needs.