Job Details

Medical Case Manager RN Prior Authorization

Company name

Orange, CA, United States

Employment Type

Case Management, Healthcare, Nursing

Posted on
Jan 08, 2022

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Medical Case Manager (RN) (Prior Authorization)


Job Description
Department(s): Utilization Management, Prior Authorization (PA)
Reports to: Supervisor, Utilization Management
FLSA status: Non-Exempt
Salary Grade: L - $37.0192 - $52.4038 ($77,000 - $109,000)

Job Summary:

This position is responsible for reviewing and processing requests for authorization and notification of medical services from health professionals, clinical facilities, and ancillary providers. The incumbent will be responsible for prior authorization and referral related processes that includes on-line responsibilities as well as selected off-line tasks. Utilizes CalOptima's medical criteria, policies, and procedures to authorize referral requests from medical professionals, clinical facilities, and ancillary providers. This position directly interacts with provider callers and serves as a resource for their needs.

Position Responsibilities:



  • Reviews requests for medical appropriateness.
  • Verifies and processes specialty referrals, diagnostic testing, outpatient procedures, home health care services and durable medical equipment and supplies via telephone or fax by using established clinical protocols to determine medical necessity.
  • Screen requests for the Medical Director review, gathers pertinent medical information prior to submission to the Medical Director; follows up with the requester by communicating the Medical Director's decision; documents follow-up in the utilization management system.
  • Completes required documentation for data entry into the utilization management system at the time of the telephone call of fax to include any authorization updates.
  • Reviews ICD-10, CPT-4 and HCPCS codes for accuracy and existence of coverage specific to the line of business.
  • Contacts the Health Networks and/or CalOptima Customer Service regarding health network enrollments.
  • Identifies and reports any complaints to immediate supervisor utilizing the call tracking system, or through verbal communication if the issue is of urgent nature.
  • Refers cases of possible over/under utilization to the Medical Director for proper reporting.
  • Meets productivity and quality of work standards on an ongoing basis.
  • Assists Manager with identifying areas of staff training needs and maintains current data resources.
  • Other projects and duties as assigned.



Knowledge & Abilities:





  • Have strong problem solving, organizational, and time management skills along with the ability to work in a fast-paced environment.
  • Communicate clearly & concisely, both verbally and in writing.
  • Travel to locations with frequency as the employer determines is necessary or desirable to meet its 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 or equivalent required.
  • Current, unrestricted RN license to practice in the State of California required.
  • 3+ years of Nursing experience of which 1+ year as a Clinical Nurse Reviewer required.
  • 1+ years of Utilization Management/ Prior Authorization Review experience required.
  • Have access means of transportation for work away from the primary office approximately 5% of the time.



Preferred Qualifications:





  • Managed Care experience preferred.
  • Active Certified Case Manager (CCM) certification preferred.



Knowledge of:





  • Current CPT-4, ICD-10, and Healthcare Common Procedure Coding System (HCPCS) codes and continual updates to knowledge base regarding the codes.
  • Medical Terminology.
  • Medi-Cal and Medicare benefits and regulations.


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:

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