Principal Duties and Responsibilities:

1. Design and execute medical management strategies that support early intervention and injury triage, ensure appropriate utilization of medical services, and promote timely return-to-work outcomes.

2. Establish clear productivity, quality, and outcome-based performance expectations tied to claim outcomes, and ensure consistent clinical decision-making aligned with evidence-based guidelines and jurisdictional requirements.

3. Manage and develop Managed Care Services team. Foster the C.A.R.E model philosophy throughout the department. Foster strong collaboration between Managed Care Services teams and Claims Adjusters to drive optimal claim resolution.

4. Oversee all external medical management vendors, including pharmacy management vendors, ancillary management vendors, utilization review vendors, case management vendors, IME and peer review providers, and medical bill review and PPO/network partners.

5. Develop and manage vendor strategy, including selection, onboarding, 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 bill reductions.

6. Conduct regular vendor scorecards, audits, and business reviews, and identify opportunities to consolidate vendors or expand capabilities to drive efficiency and quality improvement.

7. Partner closely with Claims leadership to align medical management interventions with each stage of the claim lifecycle, provide clinical support on complex and high-exposure claims, and improve adjuster adoption of medical management tools and resources.

8. Develop workflows that integrate medical management into claims systems and processes, and serve as a clinical escalation point for challenging or litigated claims.

9. Drive initiatives to reduce medical spend while improving outcomes, including reducing unnecessary or prolonged treatment, avoiding opioid overutilization, and improving network utilization.

10. Implement standardized workflows across internal and vendor operations. Identify opportunities for automation and technology enablement (e.g., workflow tools, predictive analytics). Lead continuous improvement initiatives focused on efficiency, quality, and consistency.

11. 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.

12. Ensure all activities remain aligned with state-specific Workers’ Compensation statutes and treatment guidelines, such as ODG and ACOEM.

13. Monitor and report on key metrics such as medical severity trends, lost time duration, return-to-work rates, and cost per claim, and leverage analytics to identify trends, outliers, and opportunities for targeted intervention.

Minimum Knowledge, Skills and Abilities:

1. Bachelor’s degree in Business, Healthcare Administration, Nursing, Risk Management, or related field preferred

2. Five or more years of progressive experience in Workers’ Compensation Medical Management, claims operations, or medical vendor oversight required.

3. Three plus years of previous management experience required.

4. Deep knowledge of Workers Compensation medical delivery models, utilization controls, and regulatory environments.

5. Demonstrated success managing complex, multi‑state medical vendor relationships.

6. Strong analytical, financial, and negotiation skills.

7. Clinical background (RN, CCM) or extensive experience partnering with clinical teams.

8. CPCU, CWCP, CCM, ARM, or similar designation a plus.

9. Experience supporting claims or medical transformation initiatives.