Medical Case Manager

Job Title: Medical Case Manager Location: Orange, CA 92868 Schedule: Monday – Friday | 8:00 AM – 5:00 PM (Full Office) Salary Range: $90,820 – $145,312 annually ($43.66 – $69.86 per hour) Position Summary We are currently seeking a dedicated and experienced Medical Case Manager on behalf of CalOptima Health to join the Behavioral Health Utilization Management (BHI - BH Utilization Management) team in Orange, CA. This position is responsible for reviewing medical service requests, determining medical necessity using established clinical criteria, coordinating care activities, and ensuring high-quality, member-focused service delivery. The ideal candidate will bring strong clinical expertise, utilization management experience, and the ability to thrive in a fast-paced healthcare environment. Key Responsibilities Utilization Management Services (85%) Review inpatient and outpatient authorization requests for medical necessity using established clinical guidelines. Screen cases for Medical Director review and communicate final determinations to providers and members. Prepare and distribute decision notifications in compliance with regulatory standards. Complete accurate documentation and data entry in the utilization management system. Review ICD-10, CPT-4, and HCPCS codes for accuracy and appropriate coverage determination. Coordinate Transition Care Management (TCM) activities. Identify and report complaints and potential over/under-utilization issues. Collaborate with internal teams and health networks to support enrollment and service coordination. Administrative Support (10%) Assist leadership in identifying staff training needs. Maintain updated data resources and comply with tracking protocols and reporting requirements. Other Duties (5%) Perform additional projects and responsibilities as assigned. Minimum Qualifications Current California unrestricted license (LCSW, LPCC, LMFT, or RN). Minimum three (3) years of clinical experience. Utilization Management Reviewer experience required. An equivalent combination of education and experience may be considered. Preferred Qualifications Managed care experience. Behavioral health clinical experience. Knowledge & Skills Strong analytical and problem-solving abilities. Ability to work independently and exercise sound clinical judgment. Excellent written and verbal communication skills. Strong organizational and multitasking abilities in a fast-paced environment. Proficiency in Microsoft Office (Word, Excel, Outlook, PowerPoint) and utilization management systems. Ability to build effective professional relationships with diverse internal and external stakeholders. Work Environment This is a full office-based position located in Orange, CA 92868. Work is primarily sedentary in an indoor office setting with moderate noise levels. Occasional travel or schedule flexibility may be required depending on departmental needs. Physical Requirements Ability to sit for extended periods and work at a computer. Clear verbal communication via phone and in-person interactions. Manual dexterity for typing and documentation. Ability to lift 10–25 pounds if required. Apply Today If you are a licensed clinical professional with utilization management experience seeking a stable, mission-driven opportunity in Orange County, we encourage you to apply. Ashu Team Lead – Healthcare Recruitment Direct: 510-455-4427 Aroha Technologies Inc. www.arohatechnologies.com