Director of Managed Care

Accountabilities: The Director of Managed Care will own the strategic, operational, and commercial development of the division, ensuring that each service line is launched effectively, operates compliantly, and contributes to sustainable growth. Division Strategy and Launch: Develop the overall business strategy, business plan, and phased launch roadmap for UR, MBR, NCM, and Provider Networks. Define launch priorities, resource requirements, build-versus-partner decisions, service models, pricing structures, revenue targets, and performance milestones in collaboration with executive leadership. Business Development and Revenue Growth: Establish the go-to-market and sales strategies, including integrated service offerings. Identify, develop, and secure initial clients among employers, insurers, third-party administrators, and self-insured organizations. Manage the sales pipeline, proposals, RFP responses, pricing models, contract negotiations, and industry representation. Utilization Review Development: Design and implement the UR program, including policies, procedures, and documentation required under California regulations. Support URAC accreditation efforts and establish evidence-based decision standards, clinical guidelines, turnaround benchmarks, and quality assurance processes. Recruit clinical reviewers and physician advisors while maintaining audit readiness. Medical Bill Review Development: Build the MBR service line, including fee schedule application, coding reviews, and appeals and dispute processes. Select and implement appropriate technology platforms or vendor partnerships, establishing standards for accuracy, savings, turnaround times, and client reporting. Nurse Case Management Development: Establish the NCM operating model, including clinical standards, caseload guidelines, pricing, and quality oversight. Recruit and onboard licensed clinical professionals while ensuring compliance with applicable licensing and regulatory requirements. Define performance indicators covering claim duration, medical costs, and return-to-work outcomes. Provider Network Development: Lead HCO certification and MPN approval strategies, including regulatory applications and supporting documentation. Build and manage provider networks through recruitment, credentialing, contracting, and coverage planning across required specialties and geographic areas. Establish provider data management and ongoing regulatory filing processes. Regulatory Compliance and Risk Management: Develop compliance frameworks, policies, and internal controls across all service lines before launch. Implement monitoring, reporting, and audit-readiness processes, track regulatory developments, and communicate material risks and recommended actions to executive leadership. Client Onboarding and Relationship Management: Design standardized onboarding processes across service lines and serve as the senior relationship contact for initial clients. Establish clear service expectations, lead account reviews, maintain responsive communication, and identify opportunities to expand existing client relationships. Team Building and Leadership: Define the organizational structure and workforce strategy, then recruit, hire, and develop managers and employees across all service lines. Establish performance expectations, accountability standards, and a culture of transparency and continuous improvement while aligning hiring plans with business growth. Systems, Processes, and Technology: Select and implement the platforms required to support UR, MBR, NCM, and Provider Networks. Develop integrated workflows, data management standards, quality controls, and client-facing reporting and analytics. Coordinate with IT teams and external vendors on system configuration and implementation. Financial Management: Partner with executive leadership to develop and manage the division's startup budget, staffing plan, and vendor expenses. Take ownership of P&L performance as services launch and scale, establish a path to profitability, and evaluate the financial impact of pricing decisions, operating models, and strategic investments. Executive Collaboration: Act as a strategic advisor to the COO and executive team on growth opportunities, operational risks, and market positioning. Collaborate with compliance, finance, technology, and client services teams on cross-functional priorities while identifying emerging industry trends and investment opportunities. Requirements: The ideal candidate brings extensive managed care leadership experience, a strong understanding of the workers’ compensation ecosystem, and the commercial and operational expertise needed to build multiple service lines from the ground up. Demonstrated senior leadership experience in managed care, preferably within the workers’ compensation industry. Strong knowledge of Utilization Review, Medical Bill Review, Nurse Case Management, and provider network operations (HCO/MPN). Experience designing, launching, and scaling managed care programs, business units, or service lines from inception. Familiarity with California workers’ compensation regulations, UR program requirements, HCO certification, and MPN approval processes. Experience with URAC accreditation, clinical quality standards, regulatory compliance, and audit preparation. Proven ability to develop and execute business plans, go-to-market strategies, and revenue growth initiatives. Demonstrated success acquiring and managing relationships with employers, insurers, third-party administrators, and self-insured organizations. Strong understanding of managed care pricing models, service delivery economics, budget management, and P&L accountability. Experience recruiting, developing, and leading multidisciplinary teams, including clinical professionals, operational managers, and business development staff. Familiarity with managed care technology platforms, medical bill review systems, provider network databases, and integrated reporting solutions. Strong analytical and financial skills, with the ability to translate operational performance and clinical outcomes into measurable business results. Excellent leadership, communication, negotiation, and stakeholder management abilities. Strategic thinking combined with a hands-on, entrepreneurial approach and the ability to operate effectively in a growing organization. High standards of accountability, transparency, adaptability, and continuous improvement. Benefits: Opportunity to build and lead a managed care division from the ground up. Director-level leadership position with significant strategic ownership and operational autonomy. Direct collaboration with the Chief Operating Officer and executive leadership team. Opportunity to shape business strategy, service offerings, organizational structure, and long-term growth. Broad exposure to clinical operations, business development, technology implementation, and financial management. Opportunity to make a measurable impact on the workers’ compensation industry through integrated managed care solutions. Environment focused on ownership, transparency, compassion, innovation, and technical excellence. Opportunity to grow alongside an entrepreneurial team building AI-enabled solutions for complex industries.