Medical Case Manager (BHI Utilization Management) - Impresiv Health
Orange, CA 92868
About the Job
Title: Medical Case Manager (BHI Utilization Management)
Pay Rate: $43.66 - $69.86/hour
Location: Onsite – Orange, CA
Hours: Monday – Friday, 8am-5pm
Description:
The Medical Case Manager (BHI Utilization Management) will be responsible for reviewing and processing requests for authorization and notification of behavioral health services from health professionals, clinical facilities, and ancillary providers. This role involves handling prior authorizations, concurrent review, and related processes. The successful candidate will utilize established medical criteria, policies, and procedures to authorize referral requests from behavioral health professionals, clinical facilities, and ancillary providers. The role also includes direct interaction with providers and facilities, serving as a resource for their needs.
What You Will Do:
You Will Be Successful If:
What You Will Bring:
About Impresiv Health:
Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.
Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do – provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.
That's Impresiv!
Pay Rate: $43.66 - $69.86/hour
Location: Onsite – Orange, CA
Hours: Monday – Friday, 8am-5pm
Description:
The Medical Case Manager (BHI Utilization Management) will be responsible for reviewing and processing requests for authorization and notification of behavioral health services from health professionals, clinical facilities, and ancillary providers. This role involves handling prior authorizations, concurrent review, and related processes. The successful candidate will utilize established medical criteria, policies, and procedures to authorize referral requests from behavioral health professionals, clinical facilities, and ancillary providers. The role also includes direct interaction with providers and facilities, serving as a resource for their needs.
What You Will Do:
- Participate in a mission-driven culture focused on high-quality performance, customer service, consistency, dignity, and accountability.
- Assist the team in executing department responsibilities and collaborate to support short- and long-term departmental goals and priorities.
- Review medical requests for appropriateness using established clinical protocols to determine medical necessity.
- Mail decision notifications to providers and members, as applicable.
- Screen inpatient and outpatient requests for Medical Director review, gather relevant medical information, communicate decisions to requesters, and document follow-up in the utilization management system.
- Complete documentation for data entry into the utilization management system, including authorization updates, during calls or faxes.
- Contact health networks or customer service regarding health network enrollments.
- Identify and report complaints to the immediate supervisor using the call tracking system or verbal communication for urgent issues.
- Refer cases of potential over- or under-utilization to the Medical Director for reporting.
- Conduct care coordination activities related to Transition Care Management (TCM).
- Review ICD-10, CPT-4, and HCPCS codes for accuracy and confirm coverage based on the line of business.
- Assist the manager in identifying staff training needs and maintaining current data resources.
- Comply with data tracking protocols.
- Complete other projects and duties as assigned.
You Will Be Successful If:
- Develop rapport and establish and maintain effective working relationships with the leadership and staff and external contacts at all levels and with diverse backgrounds.
- Work independently and exercise sound judgment.
- Communicate clearly and concisely, both orally and in writing.
- Work a flexible schedule; available to participate in evening and weekend events.
- Organize, be analytical, problem-solve and possess project management skills.
- Work in a fast-paced environment and in an efficient manner.
- Manage multiple projects and identify opportunities for internal and external collaboration.
- Motivate and lead multi-program teams and external committees/coalitions.
- 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.
What You Will Bring:
- Current California unrestricted license such as LCSW, LPCC, LMFT or RN and related required education PLUS 3 years of clinical experience required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.
- Utilization management reviewer experience – preferred
- Managed care experience – preferred
- Behavioral health clinical experience - preferred
About Impresiv Health:
Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.
Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do – provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.
That's Impresiv!
Source : Impresiv Health