Senior Managed Care Manager

Great American Insurance Group•Los Angeles, CA

2d•$135,000 - $183,000•Hybrid

About The Position

The Senior Managed Care Manager serves as a senior clinical resource to the claims organization, combining team leadership with hands-on expertise in managing complex workers’ compensation claims. The role oversees the coordination and evaluation of treatment plans to help ensure injured workers receive appropriate, effective, and cost-efficient care, while guiding team members in applying clinical standards, regulatory requirements, and sound case-management practices. The position provides clinical direction for complex and catastrophic cases and partners with claims professionals, healthcare providers, and vendors to improve care coordination, claim outcomes, and medical-cost management. This is a hybrid role combining in-office and remote work. Employees are expected to maintain a meaningful on-site presence; fully remote work may be considered based on the candidate’s location. Standard office hours are 8:00 a.m. to 4:30 p.m. PT.

Requirements

Bachelor’s degree in Healthcare Management, Nursing, or a related field.
Generally, a minimum of 14 years of case-management or managed-care experience, including at least 6 years of leadership experience.
Advanced knowledge of workers’ compensation clinical practices, including California MTUS, ODG Guidelines, formulary requirements, Utilization Review, and applicable medical treatment regulations.
Demonstrated experience managing complex or catastrophic cases, evaluating treatment plans, and providing clinical guidance to claims professionals and case-management staff.
Experience with provider and vendor management, medical-cost containment, treatment negotiations, CPT coding, durable medical equipment, rehabilitation services, and related contractual arrangements.
Demonstrated people-leadership experience, including coaching and developing staff, prioritizing caseloads, allocating resources, managing performance, and leading two or more direct reports.
Strong clinical judgment, communication, negotiation, collaboration, and problem-solving skills, with the ability to balance quality care, regulatory requirements, and responsible medical-cost management.

Nice To Haves

Registered Nurse (R.N.) licensure.

Responsibilities

Lead and oversee managed care activities to help ensure injured workers receive appropriate, effective, timely, and cost-efficient medical treatment.
Provide clinical expertise on complex and catastrophic workers’ compensation claims, including hospitalization, transfers of care, traumatic brain injuries, and other severe conditions.
Apply expertise in the California Medical Treatment Utilization Schedule (MTUS), ODG Guidelines, California formulary requirements, and applicable workers’ compensation medical treatment regulations.
Review complex treatment plans, care facilities, and medical-cost projections to assess clinical appropriateness and alignment with applicable standards and guidelines.
Guide staff in evaluating treatment requests for approval or referral to Utilization Review and support compliance with applicable Utilization Review requirements.
Oversee Nurse Case Management activities, including clinical direction, documentation, follow-up, reporting, and caseload prioritization.
Manage relationships with healthcare providers and medical vendors, including review of CPT coding, Letters of Agreement, durable medical equipment requests, and rehabilitation facility arrangements.
Negotiate with providers and rehabilitation facilities, challenge excessive or unnecessary treatment and equipment recommendations, and identify clinically appropriate, cost-effective alternatives.
Evaluate causation and body-part allegations and provide clinical guidance to support appropriate claims handling.
Collaborate with claimants, claims professionals, healthcare providers, vendors, and cross-functional teams to resolve treatment issues and improve care coordination and claim outcomes.
Monitor medical expenses and treatment utilization to identify opportunities for responsible cost management while maintaining appropriate standards of care.
Lead, coach, and develop staff by establishing priorities, allocating resources, managing performance, supporting talent decisions, and helping the team achieve established goals.
Monitor managed care laws and regulations, emerging legislation, medical trends, treatment strategies, and industry standards, and translate relevant developments into practical team guidance.
Participate in annual planning and goal setting and implement policies, procedures, and strategies under management direction.
Perform other duties as assigned.