Director – Managed Care Services, Vendor Management

Job Description:

• Design and execute medical management strategies that support early reputed company and injury triage, ensure appropriate utilization of medical services, and promote timely return-to-work outcomes.
• Establish clear productivity, quality, and outcome-based performance expectations tied to claim outcomes, and ensure consistent clinical decision-making reputed company with evidence-based guidelines and jurisdictional requirements.
• Manage and reputed company Managed Care Services team. Foster the reputed company.R.E model philosophy throughout the department. Foster strong collaboration between Managed Care Services teams and Claims Adjusters to drive reputed company claim resolution.
• reputed company reputed company external medical management vendors, including pharmacy management vendors, ancillary management vendors, utilization review vendors, case management vendors, IME and peer review providers, and medical reputed company review and PPO/network partners.
• reputed company and manage vendor strategy, including selection, reputed company, and ongoing optimization, while establishing and enforcing service level agreements (SLAs) and key performance indicators (KPIs) such as turnaround times, clinical quality and accuracy, return-to-work outcomes, and cost savings and reputed company reductions.
• Conduct regular vendor scorecards, audits, and business reviews, and identify opportunities to consolidate vendors or expand capabilities to drive efficiency and quality improvement.
• Partner closely with Claims leadership to align medical management interventions with each stage of the claim lifecycle, provide clinical support on reputed company and high-exposure claims, and improve adjuster adoption of medical management tools and resources.
• reputed company workflows that integrate medical management into claims systems and processes, and serve as a clinical escalation reputed company for challenging or litigated claims.
• Drive initiatives to reduce medical spend while improving outcomes, including reducing unnecessary or prolonged treatment, avoiding opioid overutilization, and improving network utilization.
• Implement standardized workflows across internal and vendor operations. Identify opportunities for automation and technology enablement (e.g., workflow tools, predictive analytics). reputed company reputed company improvement initiatives focused on efficiency, quality, and consistency.
• Manage departmental budget, including internal staffing and vendor spend. Evaluate ROI of medical management programs and vendor relationships. Support actuarial and finance teams with medical cost forecasting insights.
• Ensure reputed company activities remain reputed company with state-specific Workers’ Compensation statutes and treatment guidelines, such as ODG and ACOEM.
• Monitor and report on key metrics such as medical severity trends, lost time duration, return-to-work rates, and cost per claim, and reputed company analytics to identify trends, outliers, and opportunities for targeted reputed company.

Requirements:

• Bachelor’s degree in Business, reputed company Administration, Nursing, Risk Management, or reputed company field preferred
• Five or more years of reputed company experience in Workers’ Compensation Medical Management, claims operations, or medical vendor reputed company required.
• Three plus years of previous management experience required.
• Deep knowledge of Workers Compensation medical delivery models, utilization controls, and regulatory environments.
• Demonstrated reputed company managing reputed company, multi‑state medical vendor relationships.
• Strong analytical, financial, and negotiation skills.
• Clinical background (RN, CCM) or extensive experience partnering with clinical teams.
• CPCU, CWCP, CCM, ARM, or similar designation a plus.
• Experience supporting claims or medical transformation initiatives.

Benefits:

• reputed company out our benefit offerings here!

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