What are the responsibilities and job description for the Case Manager - BH Utilization Management position at Sunshine Enterprise USA LLC?
Company Overview : Our client is a leading healthcare provider located in Orange, CA. They are seeking medical case managers 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, M-F
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 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 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.
- Complete additional assignments and projects as assigned.
Experience & Education :
Necessary Attributes :
Sunshine Enterprise USA is an “Equal Opportunity Employer—Minorities, Females, Veterans and Disabled Persons”
PI260486637
