Senior Managed Care Manager
Core
Senior clinical resource leading managed care for complex workers' compensation claims to ensure appropriate, cost-efficient care for injured workers.
Role type
Senior Managed Care Manager (Clinical Leadership)
Builds
Care coordination and medical-cost management for workers' compensation claims
Domain
Insurance / Workers' Compensation / Healthcare Management
Required skills
Clinical judgment, Utilization Review, provider/vendor management, staff leadership, regulatory compliance (MTUS/ODG), cost management, negotiation
Preferred skills
Registered Nurse (R.N.) licensure, experience with catastrophic cases, CPT coding knowledge
Technologies
California MTUS, ODG Guidelines, CPT coding
Responsibilities
Lead managed care activities for injured workers; Provide clinical expertise on complex/catastrophic claims; Review treatment plans and medical-cost projections; Guide staff in Utilization Review; Manage relationships with healthcare providers and vendors; Negotiate with providers to challenge excessive treatment; Evaluate causation and body-part allegations; Monitor medical expenses and treatment utilization; Lead, coach, and develop staff; Monitor managed care laws and regulations.
Seniority
Senior, hands-on IC with leadership