Social Worker

Job Title :- Medical Case ManagerBuzzClan 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 DetailsDepartment: BHI - BH Utilization ManagementWork Arrangement: Full Office (Onsite)Schedule: Monday through Friday, 8:00 a.m. - 5:00 p.m.Position SummaryThe 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 & Responsibilities85% - Utilization Management ServicesParticipate 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 SupportAssist management in identifying staff training needs.Maintain updated departmental data resources.Ensure compliance with data tracking and reporting protocols.5% - Additional ResponsibilitiesComplete other duties and special projects as assigned.Minimum QualificationsCurrent 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 QualificationsManaged care experience.Behavioral health clinical experience.Required Licensure / CertificationsActive and unrestricted California license (LCSW, LPCC, LMFT, or RN).Knowledge, Skills & AbilitiesAbility 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 RequirementsAbility 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 EnvironmentOffice or Remote SiteIndoor, 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 SettingIndoor work with occasional outdoor responsibilities.Exposure to varied temperatures.Moderate to loud noise levels.Travel as required.

Created: 2026-05-13