Medical Case Manager (RN)

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. 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 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.

– 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.
– 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 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 manager with identifying areas of staff training needs and maintains current data resources. Complies with data tracking protocols.
– Assists 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.

Salary : $2,400