Medical Case Manager

Duties & Responsibilities:

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% - Other
Completes other projects and duties as assigned. 

Minimum Qualifications:

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.
Preferred Qualifications:

Managed care experience.
Behavioral health clinical experience.
Experience with behavioral health commercial non-profit criteria.
Required Licensure / Certifications:

Current California unrestricted license, such as LCSW, LPCC, LMFT or RN.
Knowledge & Abilities:

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.
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