Senior Managed Care Manager

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. This 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.

Great American’s culture is built on connection, shared learning, and strong relationships. This is a hybrid role that combines in-office and remote work. Employees are expected to maintain a meaningful on-site presence to support collaboration, relationship building, and business success. Fully remote work will be considered based on the candidates location. The standard office hours are 8:00 a.m. to 4:30 p.m. PT.

• →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.

• Bachelor’s degree in Healthcare Management, Nursing, or a related field required; Registered Nurse (R.N.) licensure preferred.
• 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.