Job Description

Job Title :- Medical Case Manager

BuzzClan is seeking an experienced and detail-oriented Medical Case Manager to support the BHI – BH Utilization Management department for our healthcare partner. This is a full-time, onsite opportunity for a licensed clinical professional with strong utilization management experience.

Position Details

• Department: BHI – BH Utilization Management
• Work Arrangement: Full Office (Onsite)
• Schedule: Monday through Friday, 8:00 a.m. – 5:00 p.m.

Position Summary

The Medical Case Manager is responsible for performing utilization management reviews, ensuring medical necessity determinations align with established clinical guidelines, and supporting care coordination efforts. This position plays a key role in maintaining a mission-driven culture focused on service excellence, accountability, dignity, and high-quality member care.

Duties & Responsibilities

85% – Utilization Management Services

• Participate in a high-performance, member-focused service culture.
• Collaborate with team members to support departmental goals and priorities.
• Review medical service requests using established clinical protocols to determine medical appropriateness and necessity.
• Mail decision notifications to providers and members as required.
• Screen inpatient and outpatient requests for Medical Director review.
• Gather relevant clinical documentation prior to submission.
• Communicate Medical Director determinations and document outcomes in the utilization management system.
• Complete documentation and authorization updates at the time of telephone or fax communication.
• Contact health networks and customer service departments regarding enrollments.
• Identify and report complaints through proper tracking systems or escalate urgent matters.
• Refer potential overutilization or underutilization cases to the Medical Director.
• Perform care coordination activities related to Transition Care Management (TCM).
• Review ICD-10, CPT-4, and HCPCS codes for accuracy and coverage compliance.

10% – Administrative Support

• Assist management in identifying staff training needs.
• Maintain updated departmental data resources.
• Ensure compliance with data tracking and reporting protocols.

5% – Additional Responsibilities

• Complete other duties and special projects as assigned.

Minimum Qualifications

• Current unrestricted California license (LCSW, LPCC, LMFT, or RN).
• Minimum of three (3) years of clinical experience.
• Utilization management reviewer experience required.
• Equivalent combination of education and experience may be considered.

Preferred Qualifications

• Managed care experience.
• Behavioral health clinical experience.

Required Licensure / Certifications

• Active and unrestricted California license (LCSW, LPCC, LMFT, or RN).

Knowledge, Skills & Abilities

• Ability to build strong professional relationships with internal and external stakeholders.
• Strong independent judgment and decision-making skills.
• Clear and concise verbal and written communication skills.
• Flexibility to work evenings or weekends if required.
• Strong analytical, organizational, and problem-solving skills.
• Ability to manage multiple priorities in a fast-paced environment.
• Experience leading or collaborating across multidisciplinary teams.
• Proficiency in Microsoft Office Suite (Word, Outlook, Excel, PowerPoint) and utilization management systems.

Physical Requirements

• Ability to read information from computer screens and printed materials.
• Clear verbal communication and hearing ability.
• Manual dexterity for typing and documentation.
• Ability to sit for extended periods.
• Ability to lift 10–25 pounds when necessary.

Work Environment

Office or Remote Site

• Indoor, sedentary work environment.
• Moderate noise levels.
• Schedule variability and potential travel.
• No harmful environmental conditions.

Clinical Setting (PACE)

• Indoor clinical environment serving frail and elderly populations.
• Potential exposure to hazardous conditions.
• Moderate to loud noise levels.

Community Setting

• Indoor work with occasional outdoor responsibilities.
• Exposure to varied temperatures.
• Moderate to loud noise levels.
• Travel as required.

Job Tags

Similar Jobs