Behavioral Health Utilization Management Medical Case Manager

Company: CalOptima
Location: Orange
Posted on: March 4, 2026

Job Description:

Behavioral Health Utilization Management Medical Case Manager CalOptima Join Us in this Amazing Opportunity The Team You'll Join We are a mission driven community?based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all. More About the Opportunity We are hoping you will join us as a Behavioral Health Utilization Management Medical Case Manager and help shape the future of healthcare where you'll be an integral part of our BHI ? BH Utilization Management team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. This position has been approved to be Full Telework. - If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum. 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. You will be responsible for prior authorizations, concurrent review and related processes. You will utilize CalOptima Health's medical criteria, policies and procedures to authorize referral requests from behavioral health professionals, clinical facilities and ancillary providers. You will directly interact with providers and facilities and serve as a resource for their needs. Together, we are building a stronger, more equitable health system. Your Contributions To the Team: - 85% ? Utilization Management Services - Participates in a mission?driven culture of high?quality performance, with a member focus on customer service, consistency, dignity and accountability. - Assists the team in carrying out department responsibilities and collaborates with others to support short? and long?term goals/priorities for the department. - 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 and/or CalOptima Health Customer Service 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. - 10% ? Administrative Support - Assists manager with identifying areas of staff training needs and maintains current data resources. - Complies with data tracking protocols. - 5% ? Other - Completes other projects and duties as assigned. Do You Have What the Role Requires? - 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. You'll Stand Out More If You Possess the Following: - Utilization management reviewer experience. - Managed care experience. - Behavioral health clinical experience. What the Regulatory Agencies Need You to Possess? - Current California unrestricted license such as LCSW, LPCC, LMFT or RN. Your Knowledge & Abilities to Bring to this Role: - Develop rapport and establish and maintain effective working relationships with CalOptima Health's 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. Your Physical Requirements (With or Without Accommodations): - Ability to visually read information from computer screens, forms and other printed materials and information. - Ability to speak (enunciate) clearly in conversation and general communication. - Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face?to?face interactions. - Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting. - Lifting and moving objects, patients and/or equipment 10 to 25 pounds Ways We Are Here For You - You'll enjoy competitive compensation for this role. - Our current hiring range is: Pay Grade: 313 ? $90,820 ? $145,312 ($43.66 ? $69.8615). - The final salary offered will be based on education, job?related knowledge and experience, skills relevant to the role and internal equity among other factors. - This position is approved for Full Telework (If the position is Telework, it is eligible in California only) - A

Keywords: CalOptima, Santa Monica , Behavioral Health Utilization Management Medical Case Manager, Healthcare , Orange, California