Medical Case Manager, BHI Utilization Management - Covered California

Medical Case Manager, BHI Utilization Management - Covered California

Join Us in this Amazing Opportunity

We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all.

More About the Opportunity

We are hoping you will join us as a Medical Case Manager, BHI Utilization Management - Covered California and help shape the future of healthcare where you'll be an integral part of our Behavioral Health team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. This position has been approved to be Full Telework.

If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum.

The Medical Case Manager (BHI Utilization Management) will be responsible for reviewing and processing requests for authorization and notification of behavioral health services from health professionals, clinical facilities and ancillary providers. You will be responsible for prior authorizations, concurrent review and related processes. You will utilize CalOptima Health's medical criteria, policies and procedures to authorize referral requests from behavioral health professionals, clinical facilities and ancillary providers. You will directly interact with providers and facilities and serve as a resource for their needs. Together, we are building a stronger, more equitable health system.

Your Contributions To the Team:

• 85% - Utilization Management Services
• Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
• Reviews requests for medical appropriateness by using established clinical protocols to determine the medical necessity of the request.
• Mails rendered decision notifications to the provider and member, as applicable.
• Screens inpatient and outpatient requests for the Medical Director's review, gathers pertinent medical information prior to submission, follows up with the requester by communicating the Medical Director's decision and documents follow-up in the utilization management system.
• Completes the required documentation for data entry into the utilization management system at the time of the telephone call or fax to include any authorization updates.
• Contacts the health networks and/or CalOptima Health Customer Service regarding health network enrollments.
• Identifies and reports any complaints to the immediate supervisor utilizing the call tracking system or through verbal communication if the issue is of an urgent nature.
• Refers cases of possible over/under utilization to the Medical Director for proper reporting.
• Completes care coordination activities as related to Transition Care Management (TCM) activities.
• Reviews International Classification of Diseases (ICD-10), Current Procedural Terminology (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) codes for accuracy and the existence of coverage specific to the line of business.
• 10% - Administrative Support
• Assists the manager with identifying areas of staff training needs and maintains current data resources.
• Complies with data tracking protocols.
• 5% - Completes other projects and duties as assigned.

Do You Have What the Role Requires?

Current California unrestricted license such as LCSW, LPCC, LMFT or RN and related required education PLUS 3 years of clinical experience required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.

Utilization management reviewer experience required.

You'll Stand Out More If You Possess the Following:

Managed care experience.

Behavioral health clinical experience.

Experience with behavioral health commercial non-profit criteria.

What the Regulatory Agencies Need You to Possess?

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

Your Knowledge & Abilities to Bring to this Role:

Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.

Work independently and exercise sound judgment.

Communicate clearly and concisely, both orally and in writing.

Work a flexible schedule; available to participate in evening and weekend events.

Organize, be analytical, problem-solve and possess project management skills.

Work in a fast-paced environment and in an efficient manner.

Manage multiple projects and identify opportunities for internal and external collaboration.

Motivate and lead multi-program teams and external committees/coalitions.

Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

Your Physical Requirements (With or Without Accommodations):

Ability to visually read information from computer screens, forms and other printed materials and information.

Ability to speak (enunciate) clearly in conversation and general communication.

Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.

Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.

Lifting and moving objects, patients and/or equipment 10 to 25 pounds

Ways We Are Here For You

You'll enjoy competitive compensation for this role.

Our current hiring range is: Pay Grade: 313 - $90,820 - $145,312 ($43.66 - $69.8615). 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.

This position is approved for Full Telework (**If the position is Telework, it is eligible in California only**).

A

CalPERS pension program and additional retirement packages.

Additional benefits and perks including:

A generous PTO program

A quality work life balance

Various wellness programs

Tuition Reimbursement

Professional development opportunities

Career development opportunities

Flexible scheduling

And the satisfaction of knowing your work directly impacts and improves healthcare access for thousands of individuals and families.

Our Work Environment:

If located at the 500, 505 Building or a remote work location:

Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.

There are no harmful environmental conditions present for this job.

The noise level in this work environment is usually moderate.

If located at PACE:

Work is typically indoors in a clinical setting serving the frail and elderly.

There may be harmful or hazardous environmental conditions present for this job.

The noise level in this work environment is usually moderate to loud.

If located in the Community:

Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.

Employee will occasionally work outdoors in varied temperatures.

There may be harmful or hazardous environmental conditions present for this job.

The noise level in this work environment is usually moderate to loud.

Why Join Us?

We believe that diverse perspectives drive innovation. Each employee brings a unique perspective to the overall team and we value everyone's input and we are committed to creating an inclusive environment where you and every team member can thrive while making a meaningful impact on our community members. Our team reflects and represents the communities we serve, and we welcome candidates from all backgrounds who share our commitment to accessible, quality healthcare.

What's Your Next Step?

All Applications will be accepted on