Please find below the details: Position: Registered Nurse/RN Department: BHI - BH Utilization Management Location: Onsite – Orange, CA 92868 Duration: 6 months (Possibilities of extensions/conversion) Shift: Day 5x8-Hour (40-hours) Schedule : Monday to Friday, 7:00 a.m. - 3:30 p.m Work Arrangement: Full Office Position Summary: This role focuses primarily on Utilization Management Services (85%) , with additional administrative and project responsibilities. The Medical Case Manager will review medical requests for appropriateness and medical necessity using established clinical protocols while ensuring compliance, accuracy, and timely communication. Key Responsibilities: Utilization Management (85%) Review requests for medical necessity using established clinical guidelines. Screen inpatient and outpatient cases for Medical Director review. Gather pertinent medical documentation and communicate determinations. Mail rendered decision notifications to providers and members. Document all activity in the utilization management system. Complete authorization updates and required data entry. Review ICD-10, CPT-4, and HCPCS codes for accuracy and coverage. Participate in Transition Care Management (TCM) activities. Identify and report complaints or utilization concerns. Collaborate with internal teams to support departmental goals. Administrative Support (10%) Assist with staff training needs. Maintain current data resources. Comply with tracking and reporting protocols. Other Duties (5%) Complete additional projects and assignments as needed. Minimum Qualifications: Current unrestricted California license (LCSW, LPCC, LMFT, or RN). Minimum 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 Skills
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