Medical Case Manager at Judge Group

The Judge Group is currently hiring full time RN Medical Case Managers for one of the largest managed care companies in Southern California! 

Are you a dedicated nursing professional looking to make a significant impact in the healthcare industry? Join our clients team as a Medical Case Manager and be at the forefront of transforming patient care. With competitive pay and a mission-driven culture, this is your chance to contribute to high-quality performance and exceptional customer service. Apply now and help us shape the future of healthcare!

Job Summary: 

The Medical Case Manager is responsible for reviewing and processing requests for authorization and notification of CalAIM services. This role involves both online and offline tasks, utilizing policies and procedures to authorize referral requests. The incumbent will interact directly with provider callers and serve as a resource for their needs, participating in a mission-driven culture of high-quality performance with a focus on customer service, consistency, dignity, and accountability.

Minimum Qualifications:

• Associate degree in nursing (ADN) required.
• 3 years of clinical experience with the health needs of the population served required.
• An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position may also be qualifying.

Preferred Qualifications:

• Bachelor’s degree in nursing (BSN).
• 2 years of experience in Long Term Care, Community Health, Managed Care Medi-Cal, Medicare programs.
• Active Commission for Case Manager (CCM) certification.
• Bilingual in English and one of CalOptima Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese).

Required Licensure / Certifications:

• Current, unrestricted Registered Nurse (RN) license to practice in the state of California required.

Key Responsibilities:

• Review authorization requests for CalAIM services for medical appropriateness utilizing medical criteria and/or established Health policies and procedures.
• Verify and process CalAIM referrals viaHealth Connect, telephone, or fax while using established clinical protocols to determine medical necessity.
• Coordinate member care with health networks, team members, and CalAIM providers.
• Complete required documentation accurately and appropriately for data entry into the utilization management or care management system at the time of the telephone call or fax, including any authorization updates.
• Determine the appropriate action regarding the service being requested for approval, modification, or denial, and refer to the Medical Director for review when necessary.
• Initiate contact with the patient, family, and CalAIM providers as needed to obtain additional information.
• Assist the team in carrying out department responsibilities and collaborate with others to support short- and long-term goals/priorities for the department.