Medical Case Manager — Orange, CA

Position Information

• Salary Range: $43.66–$56.76 per hour
• Work Arrangement: Full Office
• Work Schedule: Monday through Friday, 8:00 a.m.–5:00 p.m.
• Expected Assignment Duration: Up to six (6) months

Duties and Responsibilities

85% – Utilization Management Services

• Participates in a mission-driven culture of high-quality performance, with a focus on member customer service, consistency, dignity, and accountability.
• Assists the team in carrying out departmental responsibilities and collaborates with others to support short- and long-term goals and priorities.
• Reviews requests for medical appropriateness using established clinical protocols to determine medical necessity.
• Mails decision notifications to providers and members, as applicable.
• Screens inpatient and outpatient requests for Medical Director review, gathers pertinent medical information before submission, follows up with requesters by communicating the Medical Director’s decision, and documents follow-up in the utilization management system.
• Completes required documentation in the utilization management system at the time of telephone calls or faxes, including authorization updates.
• Contacts health networks and/or CalOptima Health Customer Service regarding health network enrollments.
• Identifies and reports complaints to the immediate supervisor through the call tracking system or verbal communication when the issue is urgent.
• Refers cases involving possible overutilization or underutilization to the Medical Director for appropriate reporting.
• Completes care coordination activities related to Transition Care Management (TCM).
• Reviews International Classification of Diseases (ICD-10), Current Procedural Terminology (CPT-4), and Healthcare Common Procedure Coding System (HCPCS) codes for accuracy and coverage under the applicable line of business.

10% – Administrative Support

• Assists the manager in identifying staff training needs and maintains current data resources.
• Complies with data tracking protocols.

5% – Other Duties

• Completes other projects and duties as assigned.

Minimum Qualifications

• Current, unrestricted California license, such as LCSW, LPCC, LMFT, or RN, and related required education, plus three (3) years of clinical experience.
• An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position may also qualify.
• Utilization management reviewer experience is required.

Preferred Qualifications

• Managed care experience.
• Behavioral health clinical experience.
• Experience with behavioral health commercial non-profit criteria.

Required Licensure and Certifications

• Current, unrestricted California license, such as LCSW, LPCC, LMFT, or RN.

Knowledge and Abilities

• Develop rapport and establish and maintain effective working relationships with CalOptima Health leadership, staff, and external contacts at all levels and from diverse backgrounds.
• Work independently and exercise sound judgment.
• Communicate clearly and concisely, both orally and in writing.
• Work a flexible schedule and be available to participate in evening and weekend events.
• Organize, analyze, solve problems, and demonstrate project management skills.
• Work efficiently in a fast-paced environment.
• Manage multiple projects and identify opportunities for internal and external collaboration.
• Motivate and lead multiprogram teams and external committees or coalitions.
• Use computers, appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, and PowerPoint), and job-specific applications or systems to produce correspondence, charts, spreadsheets, and other information applicable to the position.