X - As-Needed/TEMP - Medical Case Manager

CalOptima; Orange (CA); On-site; USD 91,000 - 145,000; Full time

Job summary

CalOptima is seeking an As-Needed/TEMP Medical Case Manager in Orange, CA. The role focuses on utilization management with a strong emphasis on customer service, documentation, and coordination.

Qualified candidates hold a CA unrestricted license (LCSW/LPCC/LMFT or RN) with at least 3 years of clinical experience. Position duration is up to six months with standard 8–5 weekday hours and full-office work arrangement.

Qualifications

• Current California unrestricted license (LCSW/LPCC/LMFT or RN) required.
• 3 years of clinical experience required; combination with education may qualify.
• Utilization management reviewer experience required.

Responsibilities

• 85% - Utilization Management Services including medical necessity reviews.
• 10% - Administrative support and data resources maintenance.
• 5% - Other duties and special projects as assigned.

Skills

Utilization management

Clinical coordination

Education

California license (LCSW/LPCC/LMFT/RN)

Job description

X - As-Needed/TEMP - Medical Case Manager

CalOptima

Position Information

• Department: Behavioral Health Integration
• Salary Grade: 313 - $90,820 - $145,312 ($43.66 - $69.8615)
• Work Arrangement: Full Office
• Work Schedule: Monday through Friday; 8:00 a.m. to 5:00 p.m.
• Expected Assignment Duration: up to six (6) months

Submission Information

• The deadline to be guaranteed full review of your submission is due by November 3, 2026 by 9:00 p.m. PST. This position will remain open for a minimum of seven (7) days, but may be extended if a lack of qualified applicants are received or if we are hiring multiple positions.

Duties & Responsibilities

• 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.
• Mails 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, 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 the 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.

Minimum Qualifications

• 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 required.

Preferred Qualifications

• Managed care experience.
• Behavioral health clinical experience.
• Experience with behavioral health commercial non-profit criteria.

Required Licensure / Certifications

• Current California unrestricted license, such as LCSW, LPCC, LMFT or RN.

Knowledge & Abilities

• 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.

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

Work Environment

If located at the 500, 505 Building or a remote work location:

• Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
• There are no harmful environmental conditions present for this job.
• The noise level in this work environment is usually moderate.

If located at PACE:

• Work is typically indoors in a clinical setting serving the frail and elderly.
• There may be harmful or hazardous environmental conditions present for this job.
• The noise level in this work environment is usually moderate to loud.

If located in the Community:

• Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
• Employee will occasionally work outdoors in varied temperatures.
• There may be harmful or hazardous environmental conditions present for this job.
• The noise level in this work environment is usually moderate to loud.

CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health 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 Health 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 at [phone] 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.

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