Judge Healthcare is seeking a Case Manager in Orange, CA!
Job Summary:
We are seeking a Care Manager to oversee and review Behavioral Health Treatment (BHT) services, including Applied Behavior Analysis (ABA), for eligible members. This role involves screening, triaging, and assessing members to determine the appropriate level of care based on medical necessity criteria. The Care Manager will review and process authorization requests for BHT services from behavioral health providers.
Key responsibilities include utilization management, quality reviews, and monitoring activities for BHT services. The Care Manager will directly interact with providers to coordinate care for BHT/ABA services.
Position Responsibilities:
Participate in a mission-driven culture focused on high-quality performance, customer service, consistency, dignity, and accountability.
Assist the team in achieving departmental goals and priorities.
Review requests for medical appropriateness and verify referrals using established clinical protocols.
Screen requests for the Medical Director's review, gather pertinent medical information, communicate the Medical Director's decision, and document follow-ups in the utilization management system.
Conduct clinical reviews based on guidelines and monitor cases involving medical decisions and quality of care.
Ensure compliance with state and federal regulatory requirements, including timelines.
Present recommendations based on clinical reviews and organizational policies to physician reviewers for final determination.
Resolve complex and sensitive member issues within established timelines.
Maintain the departmental database and ensure the accuracy of case records.
Analyze and report cases through the GARS subcommittee.
Oversee state hearing cases, discuss the appeal process, medical decisions, and hearing rights with members.
Assist members in coordinating services with providers and communicate status and outcomes.
Minimum Qualifications:
Master's degree in psychology, social work, counseling, or a related field.
4 years of experience providing ABA and/or mental health services, including clinical review and treatment plan oversight.
Equivalent combinations of education and experience that provide the necessary skills to perform the job duties are also acceptable.
