Medical Case Manager

Orange, CA - USA

Monthly Salary: Not Disclosed

Posted on: 13 hours ago

Vacancies: 1 Vacancy

Job Summary

Job Title: Medical Case Manager

Location: Orange CA 92868
Schedule: Monday Friday 8:00 AM 5:00 PM (Full Office)
Salary Range: $90820 $145312 annually ($43.66 $69.86 per hour)

Position Summary

We are currently seeking a dedicated and experienced Medical Case Manager on behalf of CalOptima Health to join the Behavioral Health Utilization Management (BHI - BH Utilization Management) team in Orange CA.

This position is responsible for reviewing medical service requests determining medical necessity using established clinical criteria coordinating care activities and ensuring high-quality member-focused service delivery. The ideal candidate will bring strong clinical expertise utilization management experience and the ability to thrive in a fast-paced healthcare environment.

Key Responsibilities Utilization Management Services (85%)

Review inpatient and outpatient authorization requests for medical necessity using established clinical guidelines.
Screen cases for Medical Director review and communicate final determinations to providers and members.
Prepare and distribute decision notifications in compliance with regulatory standards.
Complete accurate documentation and data entry in the utilization management system.
Review ICD-10 CPT-4 and HCPCS codes for accuracy and appropriate coverage determination.
Coordinate Transition Care Management (TCM) activities.
Identify and report complaints and potential over/under-utilization issues.
Collaborate with internal teams and health networks to support enrollment and service coordination.

Administrative Support (10%)

Assist leadership in identifying staff training needs.
Maintain updated data resources and comply with tracking protocols and reporting requirements.

Other Duties (5%)

Perform additional projects and responsibilities as assigned.

Minimum Qualifications

Current California unrestricted license (LCSW LPCC LMFT or RN).
Minimum three (3) years of clinical experience.
Utilization Management Reviewer experience required.
An equivalent combination of education and experience may be considered.

Preferred Qualifications

Managed care experience.
Behavioral health clinical experience.

Knowledge & Skills

Strong analytical and problem-solving abilities.
Ability to work independently and exercise sound clinical judgment.
Excellent written and verbal communication skills.
Strong organizational and multitasking abilities in a fast-paced environment.
Proficiency in Microsoft Office (Word Excel Outlook PowerPoint) and utilization management systems.
Ability to build effective professional relationships with diverse internal and external stakeholders.

Work Environment

This is a full office-based position located in Orange CA 92868. Work is primarily sedentary in an indoor office setting with moderate noise levels. Occasional travel or schedule flexibility may be required depending on departmental needs.

Physical Requirements

Ability to sit for extended periods and work at a computer.
Clear verbal communication via phone and in-person interactions.
Manual dexterity for typing and documentation.
Ability to lift 10 25 pounds if required.

Apply Today

If you are a licensed clinical professional with utilization management experience seeking a stable mission-driven opportunity in Orange County we encourage you to apply.

Ashu
Team Lead Healthcare Recruitment
Direct:
Aroha Technologies Inc.

Job Title: Medical Case Manager Location: Orange CA 92868 Schedule: Monday Friday 8:00 AM 5:00 PM (Full Office) Salary Range: $90820 $145312 annually ($43.66 $69.86 per hour) Position Summary We are currently seeking a dedicated and experienced Medical Case Manager on behalf of Ca...