Medical Case Manager, BHI Utilization Management - Covered California

About the role

We are seeking a Medical Case Manager, BHI Utilization Management - Covered California to join our Behavioral Health team. This position has been approved for full telework within the State of California. The ideal candidate will have a current California unrestricted license such as LCSW, LPCC, LMFT or RN and related required education, along with 3 years of clinical experience. This role requires utilization management reviewer experience.

Responsibilities

• Reviews and processes requests for authorization and notification of behavioral health services from health professionals, clinical facilities and ancillary providers.
• Utilizes CalOptima Health's medical criteria, policies and procedures to authorize referral requests from behavioral health professionals, clinical facilities and ancillary providers.
• Directly interacts with providers and facilities, serving as a resource for their needs.
• Works with the Medical Director to review inpatient and outpatient requests, gather pertinent medical information, and communicate the Medical Director's decisions.
• Contacts health networks and/or CalOptima Health Customer Service regarding health network enrollments.
• Screens cases for possible over/under utilization and reports them to the Medical Director.
• Completes care coordination activities as related to Transition Care Management (TCM) activities.
• Reviews ICD-10, CPT-4 and HCPCS codes for accuracy and coverage specific to the line of business.

Requirements

• Current California unrestricted license such as LCSW, LPCC, LMFT or RN and related required education.
• 3 years of clinical experience.
• Utilization management reviewer experience.
• Managed care experience.
• Behavioral health clinical experience.
• Experience with behavioral health commercial non-profit criteria.

Qualifications

• Knowledge of managed care and behavioral health commercial non-profit criteria.
• Ability to develop rapport and establish effective working relationships.
• Ability to communicate clearly and concisely, both orally and in writing.
• Ability to manage multiple projects and identify opportunities for collaboration.
• Ability to work independently and exercise sound judgment.
• Ability to manage a flexible schedule, available to participate in evening and weekend events.
• Ability to organize, be analytical, problem-solve and possess project management skills.
• Ability to manage a fast-paced environment and work efficiently.
• Ability to lift and move objects, patients and/or equipment up to 25 pounds.

Benefits

A comprehensive benefits package including a CalPERS pension program and additional retirement packages. Additional benefits and perks include a generous PTO program, quality work-life balance, various wellness programs, tuition reimbursement, professional development opportunities, career development opportunities, and flexible scheduling. The position offers competitive compensation with a pay grade range of $90,820 - $145,312 ($43.66 - $69.8615).

Pay

The final salary offered will be based on education, job-related knowledge and experience, skills relevant to the role, and internal equity among other factors.

Schedule

The position is approved for full telework within the State of California. If partial telework is required, the employee must come in to the Main Office in Orange, CA, at least two (2) days per week minimum.