• Job Description

  Req#: JP-005423277

  Job Title: Case Manager - Utilization Management

  
  

  Job Description

  Join our dynamic Utilization Management team as a Case Manager, where you will play a pivotal role in Care Coordination. You will review healthcare service requests to ensure they meet medical necessity and coverage requirements, assessing them against clinical guidelines and communicating decisions to providers and patients.

  Responsibilities

  • Perform initial review of outpatient cases, processing a minimum of 15-25 cases daily.
  • Review designated requests for referral authorizations and prior authorizations proactively, concurrently, or retroactively.
  • Ensure compliance with turnaround times and accuracy standards.
  • Coordinate with contracted providers when authorizing services.
  • Collaborate with contracting to obtain appropriate contracts as necessary.
  • Identify cases requiring additional case management and coordinate care with appropriate departments and internal staff.

  Essential Skills

  • 2+ years of prior authorization outpatient experience.
  • Knowledge of Medicare, MediCal, and Milliman Criteria Guidelines.
  • Experience in utilization management and working with provider offices.
  • Proficiency in MCG criteria and standards.

  Additional Skills & Qualifications

  • Familiarity with EZ-CAP system is a plus; must be computer competent.
  • High School Diploma or GED required; Bachelor's of Science in Nursing or other clinical advanced degree preferred.
  • 1+ year of managed care experience preferred.
  • 1+ year of inpatient experience preferred.
  • Understanding of nursing processes, case management, and continuity of care.
  • Ability to apply criteria to identify appropriate level of care on all admissions.
  • Knowledge of network and benefit limitations, collaborating with stakeholders to find alternatives.
  • Understanding of disease management strategies.

  Work Environment

  Enjoy a structured work schedule from Monday to Friday, 8am to 5pm, with a one-hour lunch break. While primarily a remote environment, you may be requested to support some holidays and weekends if necessary.

  Pay and Benefits

  The pay range for this position is $29.00 - $37.00/hr.

  Eligibility requirements apply to some benefits and may depend on your job
  classification and length of employment. Benefits are subject to change and may be
  subject to specific elections, plan, or program terms. If eligible, the benefits
  available for this temporary role may include the following:

  • Medical, dental & vision
  • Critical Illness, Accident, and Hospital
  • 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available
  • Life Insurance (Voluntary Life & AD&D for the employee and dependents)
  • Short and long-term disability
  • Health Spending Account (HSA)
  • Transportation benefits
  • Employee Assistance Program
  • Time Off/Leave (PTO, Vacation or Sick Leave)

  Workplace Type

  This is a fully remote position.

  Application Deadline

  This position is anticipated to close on Aug 1, 2025.

  About Actalent

  Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.

  The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

  If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing due to a disability, please email actalentaccommodation@actalentservices.com for other accommodation options.

• About the company

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