Senior Managed Care Manager

Great American Insurance Group; Los Angeles (CA); Híbrido; USD 135 000 - 183 000; Tempo integral

Vantagens oferecidas por esta oferta de emprego

Medical, dental, and vision coverage

401(k) with company match

Paid time off and holidays

Resumo da oferta

Great American Insurance Group’s Republic Indemnity division seeks a Senior Managed Care Manager to lead the claims team in coordinating high‑quality, cost‑effective medical care for California and western states’ workers’ compensation claims.

The role combines team leadership with hands‑on clinical expertise, partnering with providers, vendors and claims professionals to improve care coordination, outcomes, and medical-cost management. Hybrid in-office/remote work available.

Qualificações

• Bachelor’s degree in healthcare management or nursing; RN licensure preferred.
• Minimum 14 years of case-management or managed-care experience, including 6 years in leadership.
• Advanced knowledge of MTUS, ODG Guidelines, formulary requirements, and regulatory requirements.
• Experience managing complex or catastrophic cases and guiding claims professionals.
• Experience with provider/vendor management, medical-cost containment, CPT coding, rehab services.
• Strong leadership, communication, negotiation, collaboration and problem-solving skills.

Responsabilidades

• Lead and oversee managed care activities to ensure appropriate, effective, timely, and cost-efficient treatment.
• Provide clinical expertise on complex and catastrophic claims, including hospitalizations and transfers.
• Apply MTUS, ODG, formulary requirements and applicable regulations.
• Review treatment plans and medical-cost projections for appropriateness.
• Guide staff in evaluating treatment requests and UR requirements.
• Oversee Nurse Case Management including direction, documentation, and caseload prioritization.
• Negotiate with providers and facilities for cost-effective treatments and equipment.
• Monitor medical expenses and utilization to balance care and costs.

Conhecimentos

Leadership

Clinical expertise

Negotiation

Collaboration

Communication

Problem solving

Formação académica

Bachelor’s degree in Healthcare Management, Nursing, or related field

Descrição da oferta de emprego

Be Here. Be Great. Working for a leader in the insurance industry means opportunity for you. Great American Insurance Group’s member companies are subsidiaries of American Financial Group. We combine a \"small company\" culture where your ideas will be heard with \"big company\" expertise to help you succeed. With over 35 specialty property and casualty operations, there are always opportunities here to learn and grow. At Great American, we value and recognize the benefits derived when people with different backgrounds and experiences work together to achieve business results. Our goal is to create a workplace where all employees feel included, empowered, and enabled to perform at their best.

For over 50 years, Republic Indemnity has been a trusted partner for businesses across the western U.S., helping them effectively manage their workers' compensation costs. Our headquarters in Woodland Hills, California, along with an additional office in San Francisco, to serve a hub for our operations. We specialize in workers' compensation in California and other western states, along with capabilities to support multistate accounts across the US.

Our Vision: Clear Paths to Success At Republic, we believe in creating clear pathways for everyone - whether it's a broker, policyholder, injured worker, or colleague. We're committed to helping people reach their goals and achieve success.

This position is not eligible for employment visa sponsorship. Applicants must be authorized to work in the United States without the need for current or future sponsorship.

Division Overview

Republic Indemnity markets workers’ compensation insurance to a wide range of clients, primarily in California and the western United States. With a focus on strong results and exceptional service, we are committed to meeting the needs of our customers and delivering positive outcomes. Our employees play an important role in supporting that commitment and contributing to the success of the business. We offer ongoing opportunities to learn, grow, and build a rewarding career.

Position Overview

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.

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.

Qualifications

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.

Company

RICA Republic Indemnity Company of America

Salary Range

$135,000.00 -$183,000.00

Benefits

• Full-time employees have access to medical, dental, and vision coverage, wellness plans, parental leave, adoption assistance, and tuition reimbursement.
• Full-time and eligible part‑time employees also enjoy Paid Time Off and paid holidays, a 401(k) plan with company match, an employee stock purchase plan, and commuter benefits.

Compensation varies by role, level, and location and is influenced by skills, experience, and business needs. Your recruiter will provide details about benefits and specific compensation ranges during the hiring process.

Learn more at http://www.gaig.com/careers.

Great American Insurance Group understands the importance of choosing a financially strong company. We are an organization built for the long term and are committed to giving you that strength. Why can you trust Great American Insurance Group? For nearly 150 years, Americans have trusted us to protect them. Our innovative insurance solutions and specialization serves niche marketplaces that we know well. This expertise gives us a successful foundation that spans generations. You never know where a career in insurance will take you. Whether you are starting your career or are looking for a company to grow your experience, at Great American Insurance Group, you can join our more than 8,500 employees to “Be Here. Be GREAT!” To learn more, visit our Career Page