Medical Case Manager RN BHI Utilization Management
Medical Case Manager RN BHI Utilization Management
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5years
$ $ 48 - 55
1 Vacancy
Job Description
Company Overview: Our client is a leading healthcare located in Orange CA seeking a medical case manager who will be responsible for reviewing and processing requests for authorization and notification of behavioral health services from health professionals clinical facilities and ancillary providers.
Position Summary: The successful candidate should hold a current unrestricted registered nurse (RN) licensed clinical social worker (LCSW) licensed professional clinical counselor (LPCC) or Licensed Marriage and Family Therapist (LMFT) to practice in the state of California and 3 years of clinical experience with utilization management and managed care background.
Work Duration: Up to 6 months
Work hours: 8 am 5 pm MF
Position Responsibilities:
- Reviews requests for medical appropriateness by using established clinical protocols to determine the medical necessity of the request.
- Responsible for mailing 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 to the Medical Director follows up with the requester by communicating the Medical Director s decision and documents followup 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 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 (ICD10) Current Procedural Terminology (CPT4) and Healthcare Common Procedure Coding System (HCPCS) codes for accuracy and the existence of coverage specific to the line of business.
- Complete additional assignments and projects as assigned.
Experience & Education:
Current unrestricted LCSW LPCC LMFT or RN license to practice in the state of California required
3 years of clinical experience with managed care behavioral health clinical and utilization management reviewer experience required.
Necessary Attributes:
- Establish effective relationships with internal and external stakeholders.
- Demonstrate independent judgment and decisionmaking skills.
- Communicate effectively both verbally and in writing.
- Flexible schedule availability for evening and weekend events.
- Strong organizational analytical and problemsolving abilities.
- Proficiency in Microsoft Office (Word Outlook Excel PowerPoint) and jobspecific applications/systems.
Please see HR for information on physical demands and work environment of this job.
Sunshine Enterprise USA is an Equal Opportunity Employer Minorities Females Veterans and Disabled Persons
Proficiency in advanced anesthesia techniques for cardiac surgeries. Strong knowledge of critical care principles and management of cardiac conditions. Excellent communication and interpersonal skills, with the ability to work collaboratively in a fast-paced, high-pressure environment. Detail-oriented with strong organizational skills. Ability to make quick and informed decisions during medical emergencies.
Education
Minimum of 3 years of experience in cardiac anesthesia and ICU care, preferably in a hospital or healthcare setting with a high volume of cardiac surgeries. Demonstrated expertise in managing critically ill cardiac patients in the ICU.
Employment Type
Full Time
