Caloptima Jobs in Usa
2 positions found
C
Behavioral Health Utilization Management Medical Case Manager
Salary not disclosed
Behavioral Health Utilization Management Medical Case Manager
CalOptima
Join Us in this Amazing Opportunity
The Team You'll Join
We are a mission driven community‐based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all.
More About the Opportunity
We are hoping you will join us as a Behavioral Health Utilization Management Medical Case Manager and help shape the future of healthcare where you'll be an integral part of our BHI ‐ BH Utilization Management team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. This position has been approved to be Full Telework.
- If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum.
The Medical Case Manager (BHI Utilization Management) will be responsible for reviewing and processing requests for authorization and notification of behavioral health services from health professionals, clinical facilities and ancillary providers. You will be responsible for prior authorizations, concurrent review and related processes. You will utilize CalOptima Health's medical criteria, policies and procedures to authorize referral requests from behavioral health professionals, clinical facilities and ancillary providers. You will directly interact with providers and facilities and serve as a resource for their needs. Together, we are building a stronger, more equitable health system.
Your Contributions To the Team:
- 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.
- Responsible for mailing 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 to the Medical Director, 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 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.
Do You Have What the Role Requires?
- 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.
You'll Stand Out More If You Possess the Following:
- Utilization management reviewer experience.
- Managed care experience.
- Behavioral health clinical experience.
What the Regulatory Agencies Need You to Possess?
- Current California unrestricted license such as LCSW, LPCC, LMFT or RN.
Your Knowledge & Abilities to Bring to this Role:
- 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.
Your 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
Ways We Are Here For You
- You'll enjoy competitive compensation for this role.
- Our current hiring range is: Pay Grade: 313 ‐ $90,820 ‐ $145,312 ($43.66 ‐ $69.8615).
- The final salary offered will be based on education, job‐related knowledge and experience, skills relevant to the role and internal equity among other factors.
- This position is approved for Full Telework (**If the position is Telework, it is eligible in California only**)
- A
CalOptima
Join Us in this Amazing Opportunity
The Team You'll Join
We are a mission driven community‐based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all.
More About the Opportunity
We are hoping you will join us as a Behavioral Health Utilization Management Medical Case Manager and help shape the future of healthcare where you'll be an integral part of our BHI ‐ BH Utilization Management team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. This position has been approved to be Full Telework.
- If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum.
The Medical Case Manager (BHI Utilization Management) will be responsible for reviewing and processing requests for authorization and notification of behavioral health services from health professionals, clinical facilities and ancillary providers. You will be responsible for prior authorizations, concurrent review and related processes. You will utilize CalOptima Health's medical criteria, policies and procedures to authorize referral requests from behavioral health professionals, clinical facilities and ancillary providers. You will directly interact with providers and facilities and serve as a resource for their needs. Together, we are building a stronger, more equitable health system.
Your Contributions To the Team:
- 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.
- Responsible for mailing 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 to the Medical Director, 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 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.
Do You Have What the Role Requires?
- 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.
You'll Stand Out More If You Possess the Following:
- Utilization management reviewer experience.
- Managed care experience.
- Behavioral health clinical experience.
What the Regulatory Agencies Need You to Possess?
- Current California unrestricted license such as LCSW, LPCC, LMFT or RN.
Your Knowledge & Abilities to Bring to this Role:
- 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.
Your 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
Ways We Are Here For You
- You'll enjoy competitive compensation for this role.
- Our current hiring range is: Pay Grade: 313 ‐ $90,820 ‐ $145,312 ($43.66 ‐ $69.8615).
- The final salary offered will be based on education, job‐related knowledge and experience, skills relevant to the role and internal equity among other factors.
- This position is approved for Full Telework (**If the position is Telework, it is eligible in California only**)
- A
C
Registration Representative
Salary not disclosed
Job Title: Registration Representative Location: Laguna Hills, CA 92653 Duration: 3 months+ (Possible Extension) Pay Range: $22 to $25 per hour.
on W2 Note: • Schedule is Saturday 6:30 AM – 5 PM Sunday 6:30 AM – 5 PM Monday 6:30 AM – 5 PM Tuesday – 9 AM
- 7:30 PM • Highly preferred to have Urgent care/Doctors’ office/Dental office experience Must have solid health insurance background.
Job Summary: · This position requires the full understanding and active participation in fulfilling the mission of.
· It is expected that the employee will demonstrate behavior consistent with our core values: Integrity, Accountability, Best Practices, Compassion and Synergy.
· The employee shall support ’s strategic plan and participate in and advocate performance improvement/patient safety activities.
· The Registration Representative is under the direction of the Supervisor/ Manager and is responsible for completing all registrations of patients presenting for procedures, admissions, outpatient and ER visits.
· The Representative must obtain and verify demographic and insurance information so that the patient can be accurately identified and billed for their services.
· The registration representative is responsible for collecting and posting the patient’s financial responsibility in Epic and immediately dropping the payment in the safe or locked cash drawer.
· Excellent customer service must be maintained with all patients, visitors, clinicians, and co-workers.
Skills: · Ability to communicate effectively in written and verbal form · Adheres to department policy of using two patient identifiers.
· Avoids HIPAA violations by choosing correct MRN and interviews, registers, and pre-registers patients timely and accurately in Epic.
· Ensures all registration forms are complete, signed, and scanned.
Enter notes in Epic as required.
· Ability to provide excellent customer service using Simply Better and AIDET principles.
· Collects and posts payments timely and accurately.
Immediately drops payment in safe or cash drawer.
· Ability to follow company policies, supports department performance improvement activities.
(Staff meetings, employee engagement survey, education, and training activities) · Maintains registration accuracy rate of 95% or better.
· Monitors and manages work queues.
· Ability to be at work and be on time.
Adheres to MHS time and attendance policy.
· Ability to follow company policies, procedures, and directives.
Supports department performance improvement activities.
(Meetings, employee engagement survey, education, and training activities) · Ability to interact in a positive and constructive manner.
· Ability to prioritize and multitask.
Essential Job Outcomes: · Adheres to department policy of using two patient identifiers ensuring correct information appears on all documents, armbands, and labels.
Adheres to a verbal verification of armband placement.
· Avoids HIPAA violations by accurately entering information into the Epic system to avoid passing on defects; such as incorrect patient name, PCP, guarantor and insurance information.
· Interviews, pre-registers and registers patients timely and accurately.
Appropriate level of expertise in Epic, OnBase, RTE, insurance websites to ensure accurate and efficient registrations.
· Ensures that all registration forms are complete, signed, scanned and indexed in Epic timely.
Enters notes in referral or auth/cert and uses billing indicator as needed.
· Delivers excellent customer service using “Simply Better” and AIDET principles with patients, staff, and visitors.
Maintains effective working relationships with co-workers and others.
Utilizing Simply Better recognition cards or any other communication regarding customer service.
· Collects and posts patient financial responsibility; including deposits, copays, deductibles, estimates, and/or coinsurance timely and accurately.
Drops payment in the safe or cash drawer timely.
Based on a monthly department cash collection goal.
· Participates in and supports department specific performance improvement education, training, staff meetings, and projects.
(Employee Engagement survey, service excellence, etc.) Promotes and participates in the employee engagement action plan).
Assists with improving the score.
· Maintains an accuracy of 95% or better by selecting the correct insurance plan and IPA code.
Monitors and manages assigned work queues to maximize productivity by meeting department standards.
Appropriate level of expertise in Epic, Onbase, RTE and insurance websites to ensure accurate and efficient registrations.
· Monitors assigned WQ’s to maximize productivity by meeting department weekly goals.
· Adheres to MHS time and attendance policy #357.
Clocks “in and out” of MTM accurately with minimal clocking errors for each scheduled shift.
Signs off by the end of the pay period.
· Other duties as assigned.
Experience: • 1-2 years of experience in hospital admitting, physician office, or equivalent healthcare • Must communicate effectively and clearly both verbally and in writing • Strong customer service skills • General knowledge of insurance payors: PPO, HMO, POS, EPO, Medicare, Medi-Cal, & CalOptima • Bi-lingual (English/Spanish, or English/Vietnamese) preferred • Positive work ethic • General computer skills required including electronic medical record and Microsoft Office • Knowledge of medical terminology
on W2 Note: • Schedule is Saturday 6:30 AM – 5 PM Sunday 6:30 AM – 5 PM Monday 6:30 AM – 5 PM Tuesday – 9 AM
- 7:30 PM • Highly preferred to have Urgent care/Doctors’ office/Dental office experience Must have solid health insurance background.
Job Summary: · This position requires the full understanding and active participation in fulfilling the mission of.
· It is expected that the employee will demonstrate behavior consistent with our core values: Integrity, Accountability, Best Practices, Compassion and Synergy.
· The employee shall support ’s strategic plan and participate in and advocate performance improvement/patient safety activities.
· The Registration Representative is under the direction of the Supervisor/ Manager and is responsible for completing all registrations of patients presenting for procedures, admissions, outpatient and ER visits.
· The Representative must obtain and verify demographic and insurance information so that the patient can be accurately identified and billed for their services.
· The registration representative is responsible for collecting and posting the patient’s financial responsibility in Epic and immediately dropping the payment in the safe or locked cash drawer.
· Excellent customer service must be maintained with all patients, visitors, clinicians, and co-workers.
Skills: · Ability to communicate effectively in written and verbal form · Adheres to department policy of using two patient identifiers.
· Avoids HIPAA violations by choosing correct MRN and interviews, registers, and pre-registers patients timely and accurately in Epic.
· Ensures all registration forms are complete, signed, and scanned.
Enter notes in Epic as required.
· Ability to provide excellent customer service using Simply Better and AIDET principles.
· Collects and posts payments timely and accurately.
Immediately drops payment in safe or cash drawer.
· Ability to follow company policies, supports department performance improvement activities.
(Staff meetings, employee engagement survey, education, and training activities) · Maintains registration accuracy rate of 95% or better.
· Monitors and manages work queues.
· Ability to be at work and be on time.
Adheres to MHS time and attendance policy.
· Ability to follow company policies, procedures, and directives.
Supports department performance improvement activities.
(Meetings, employee engagement survey, education, and training activities) · Ability to interact in a positive and constructive manner.
· Ability to prioritize and multitask.
Essential Job Outcomes: · Adheres to department policy of using two patient identifiers ensuring correct information appears on all documents, armbands, and labels.
Adheres to a verbal verification of armband placement.
· Avoids HIPAA violations by accurately entering information into the Epic system to avoid passing on defects; such as incorrect patient name, PCP, guarantor and insurance information.
· Interviews, pre-registers and registers patients timely and accurately.
Appropriate level of expertise in Epic, OnBase, RTE, insurance websites to ensure accurate and efficient registrations.
· Ensures that all registration forms are complete, signed, scanned and indexed in Epic timely.
Enters notes in referral or auth/cert and uses billing indicator as needed.
· Delivers excellent customer service using “Simply Better” and AIDET principles with patients, staff, and visitors.
Maintains effective working relationships with co-workers and others.
Utilizing Simply Better recognition cards or any other communication regarding customer service.
· Collects and posts patient financial responsibility; including deposits, copays, deductibles, estimates, and/or coinsurance timely and accurately.
Drops payment in the safe or cash drawer timely.
Based on a monthly department cash collection goal.
· Participates in and supports department specific performance improvement education, training, staff meetings, and projects.
(Employee Engagement survey, service excellence, etc.) Promotes and participates in the employee engagement action plan).
Assists with improving the score.
· Maintains an accuracy of 95% or better by selecting the correct insurance plan and IPA code.
Monitors and manages assigned work queues to maximize productivity by meeting department standards.
Appropriate level of expertise in Epic, Onbase, RTE and insurance websites to ensure accurate and efficient registrations.
· Monitors assigned WQ’s to maximize productivity by meeting department weekly goals.
· Adheres to MHS time and attendance policy #357.
Clocks “in and out” of MTM accurately with minimal clocking errors for each scheduled shift.
Signs off by the end of the pay period.
· Other duties as assigned.
Experience: • 1-2 years of experience in hospital admitting, physician office, or equivalent healthcare • Must communicate effectively and clearly both verbally and in writing • Strong customer service skills • General knowledge of insurance payors: PPO, HMO, POS, EPO, Medicare, Medi-Cal, & CalOptima • Bi-lingual (English/Spanish, or English/Vietnamese) preferred • Positive work ethic • General computer skills required including electronic medical record and Microsoft Office • Knowledge of medical terminology
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