Job Details

Medical Case Manager RN BHI - TCM

Company name
CalOptima

Location
Orange, CA, United States

Employment Type
Full-Time

Industry
Case Management, Nursing

Posted on
Nov 22, 2021

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Medical Case Manager (RN) (BHI - TCM)

 


Job Description
Department(s): Behavioral Health Integration
Reports to: Manager, Behavioral Health (Care Management)
FLSA status: Non-Exempt
Salary Grade: L - $37.0192 - $52.4038 ($77,000 - $109,000)



Job Summary

This Medical Case Manager (RN) (Behavioral Health Integration - Transition Care Management) is responsible for reviewing and processing requests for authorization and notification of behavioral health outpatient and psychiatric inpatient services from health professionals, clinical facilities, and ancillary providers. The incumbent will be responsible for behavioral health prior authorizations, inpatient concurrent review, and processes related to transitional care. The incumbent utilizes CalOptima's medical criteria, policies, and procedures to authorize referral requests from behavioral health professionals, clinical facilities, and ancillary providers. This position directly interacts with provider facilities, and members.



Position Responsibilities:

 

 

  • Completes inpatient psychiatric concurrent review and works closely with inpatient psychiatric units to coordinate transitional care.
  • Participates in weekly inpatient clinical concurrent review meetings with the Behavioral Health Medical Director.
  • Receives, verifies, and processes prior authorization requests for outpatient behavioral health services.
  • Reviews requests for medical appropriateness by using established clinical protocols to determine the medical necessity of the request.
  • Generates and processes denial and modification notifications to meet regulatory standards.
  • Responsible for mailing rendered decision notifications to the provider and member, as applicable.
  • Triages, manages, and processes complex requests and reviews including but not limited to, high utilizing members, retro reviews, specialized authorizations, etc.
  • Provides consultation to Applied Behavioral Analysis (ABA) Care Manager when medical record review is needed.
  • Collaborates with Transition Care Management (TCM) staff for coordination of care.
  • Documents into the electronic medical records system according to CalOptima's guidelines and protocols.
  • Reviews ICD-10, CPT-4, and Healthcare Common Procedure Coding System (HCPCS) codes for accuracy and existence of coverage specific to the line of business.
  • Meets productivity and quality of work standards on an ongoing basis.
  • Complies with data tracking protocols.
  • Other projects and duties as assigned.

 

 


Possesses the Ability To:

 

 

 

 

  • Maintain current CPT-4, ICD-10 and HCPCS codes and continual updates to knowledge base regarding the codes.
  • Communicate clearly and concisely, both verbally and in writing.
  • Work independently with minimal supervision or guidance.
  • Establish and maintain effective working relationships with CalOptima leadership and staff.
  • Travel to locations as necessary to meet business needs.
  • Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

 


Experience & Education:

 

 

 

  • High School diploma required
  • Current Registered Nurse (RN) license to practice in the State of California required.
  • 3 years of clinical experience required.

 


Preferred Qualifications:

 

 

 

  • Associates degree in Health Care Administration, Psychology, or related field preferred.
  • Inpatient behavioral health experience preferred.
  • Managed Care experience preferred.
  • Active Certified Case Manager (CCM) certification preferred.

 

 


Knowledge of:

 

 

 

 

  • Strong problem solving, organizational skills, and time management skills with the ability to work in a fast-paced environment.

 


CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. You can request reasonable accommodations by contacting Human Resources Disability Management at 657-900-1134.


Job Location: Orange, California
Position Type:

To apply, visit https://jobs.silkroad.com/CalOptima/Careers/jobs/3522






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Company info

CalOptima

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