Medical Case Manager (RN)

About the Role

We are seeking a dedicated Registered Nurse (RN) to join our team as a Medical Case Manager. In this role, you will review medical necessity for Community-Based Adult Services (CBAS), perform clinical assessments, coordinate with providers and caregivers, and support utilization management while ensuring compliance with Medi-Cal guidelines and organizational policies. This position is ideal for an RN with experience in case management, utilization review, care coordination, or authorization review who enjoys working in a collaborative, fast-paced healthcare environment.

Responsibilities

• Review CBAS service requests for medical necessity using Medi-Cal criteria and established policies.
• Perform clinical assessments using standardized tools, including the CBAS Eligibility Determination Tool (CEDT) and Individual Plan of Care (IPC).
• Approve, modify, or deny service requests based on clinical findings and established guidelines.
• Prepare and present complex cases to the Medical Director when appropriate.
• Communicate authorization decisions to providers and document all activities in the care management system.
• Coordinate with physicians, caregivers, family members, CBAS providers, IHSS, CalAIM, and skilled nursing facilities.
• Maintain accurate clinical documentation, diagnosis coding, and authorization records.
• Identify high-risk or high-cost cases requiring advanced case management intervention.
• Meet established productivity and quality standards.
• Perform additional duties as assigned.

Qualifications

Minimum Qualifications

• Associate Degree in Nursing (ADN) or equivalent combination of education and experience.
• Minimum 3 years of nursing experience.
• Current, unrestricted California Registered Nurse (RN) license.

Preferred Qualifications

• 1+ year of authorization review or utilization management experience.
• Experience with CBAS, Medi-Cal, managed care, utilization review, or case management.
• Bilingual in English and one of the following languages: Spanish, Vietnamese, Chinese, Korean, Arabic, Farsi, or Russian.

Required Skills

• Case Management
• Utilization Review
• Medical Necessity Review
• Clinical Assessment
• Care Coordination
• Managed Care
• Medi-Cal Guidelines
• Authorization Review
• Clinical Documentation
• Microsoft Office Suite
• Strong communication and analytical skills

Location: Orange, CA (Onsite)
Job Type: Temporary (Up to 6 Months)
Schedule: Monday – Friday | 8:00 AM – 5:00 PM