Medical Case Manager

Location:

Onsite – Orange, CA 92868

6 months (Possibilities of extensions/conversion)

Day 5x8-Hour (40-hours)

Monday to Friday, 7:00 a.m.

- 3:30 p.m

Full Office

This role focuses primarily on Utilization Management Services (85%), with additional administrative and project responsibilities. The Medical Case Manager will review medical requests for appropriateness and medical necessity using established clinical protocols while ensuring compliance, accuracy, and timely communication.

• Review requests for medical necessity using established clinical guidelines.
• Screen inpatient and outpatient cases for Medical Director review.
• Gather pertinent medical documentation and communicate determinations.
• Mail rendered decision notifications to providers and members.
• Document all activity in the utilization management system.
• Complete authorization updates and required data entry.
• Review ICD-10, CPT-4, and HCPCS codes for accuracy and coverage.
• Participate in Transition Care Management (TCM) activities.
• Identify and report complaints or utilization concerns.
• Collaborate with internal teams to support departmental goals.

• Assist with staff training needs.
• Comply with tracking and reporting protocols.

• Complete additional projects and assignments as needed.

• Current unrestricted California license (LCSW, LPCC, LMFT, or RN).
• Minimum 3 years of clinical experience
  .
• Equivalent combination of education and experience may be considered.

• Managed care experience.
• Behavioral health clinical experience.

• Strong clinical judgment and independent decision-making skills.
• Excellent verbal and written communication skills.
• Ability to work in a fast-paced environment and manage multiple priorities.
• Analytical and problem-solving skills.
• Proficiency in Microsoft Office (Word, Excel, Outlook, PowerPoint) and relevant systems.
• Ability to build rapport with diverse internal and external stakeholders.