Medical Case Manager (LVN) (PACE - Utilization Management)

Medical Case Manager (LVN) (PACE - Utilization Management)

Job no: 494176
Work type: Full Time
Location: PACE - Garden Grove
Categories: Medical / Clinical

More About the Opportunity

We are hoping you will join us as a Medical Case Manager (LVN) (PACE-Utilization Management) and help shape the future of healthcare where you'll be an integral part of our PACE- Clinic 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 Partial 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 (LVN) for the Program for All-Inclusive Care for the Elderly (PACE) is responsible for reviewing and processing requests for authorization and notification of medical services from health professionals, clinical facilities, and ancillary providers. You will be responsible for prior authorization, concurrent review and referral related processes which include on-line responsibilities as well as selected off-line tasks. You utilizes PACE medical criteria, policies, and procedures to authorize referral requests from medical professionals, clinical facilities, and ancillary providers. You directly interacts with provider callers and serves as a resource for their needs. Together, we are building a stronger, more equitable health system.

Your Contributions To the Team:

• 95% - Case Management
  • 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 for inpatient and outpatient services utilizing medical criteria and/or established policies and procedures.
  • Verifies and processes specialty referrals, diagnostic testing, outpatient procedures, home health care services and durable medical equipment and supplies via telephone or fax by using established clinical protocols to determine medical necessity.
  • Screens inpatient and outpatient requests for the PACE Medical Director review, gathers pertinent medical information prior to submission to the PACE Medical Director; follows up with the requester by communicating the PACE Medical Director's decision; documents follow-up in the utilization management system.
  • Completes required documentation for data entry into the utilization management system at the time of receipt to include any authorization updates.
  • Reviews ICD-10, CPT-4, and Healthcare Common Procedure Coding System (HCPCS) codes for accuracy and existence of coverage specific to the PACE.
  • Ensures all internal and external PACE authorizations are complete with CPT codes, notes and pertinent information.
  • Reviews the appropriateness of retro authorizations for review and works with the PACE Medical Director for proper review and authorizations.
  • Reviews and follows up on denied claims and provider disputes/appeals to ensure accuracy of information and maintain partnerships with our contracted specialty offices.
  • Refers cases of possible over/under utilization to the PACE Medical Director for proper reporting and reviewing.
  • Meets PACE productivity and quality of work standards on an ongoing basis.
  • Assists the manager with identifying areas of need for staff training and maintains current data resources.

• 5% - Other
  • Completes other projects and duties as assigned.

Do You Have What the Role Requires?

• High school diploma or equivalent PLUS 3 years of nursing experience, with 1 year as a nurse reviewer, 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.
• CPR and First-Aid Certification required or must be obtained within six (6) months of date of hire.

You'll Stand Out More If You Possess the Following:

• Managed care experience.
• Concurrent review experience.

What the Regulatory Agencies Need You to Possess?

• Current unrestricted Licensed Vocational Nurse (LVN) license to practice in the state of California.

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: 311 - $77,863 - $124,581 ($37.43 - $59.8947).
    • 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 Partial Telework (**If the position is Telework, it is eligible in California only**)
• A comprehensive benefits package
• CalPERS pension program and additional retirement packages.
• Additional benefits and perks including:
  • A generous PTO program
  • A quality work life balance
  • Various wellness programs
  • Tuition Reimbursement
  • Professional development opportunities
  • Career development opportunities
  • Flexible scheduling
  • And the satisfaction of knowing your work directly impacts and improves healthcare access for thousands of individuals and families.

Our Work Environment:

If located at the 500, 505 Building or a remote work location:

• Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
• There are no harmful environmental conditions present for this job.
• The noise level in this work environment is usually moderate.

If located at PACE:

• Work is typically indoors in a clinical setting serving the frail and elderly.
• There may be harmful or hazardous environmental conditions present for this job.
• The noise level in this work environment is usually moderate to loud.

If located in the Community:

• Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
• Employee will occasionally work outdoors in varied temperatures.
• There may be harmful or hazardous environmental conditions present for this job.
• The noise level in this work environment is usually moderate to loud.

What's Your Next Step?

All Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. Do NOT miss out. If you want to join our team, the deadline for the first review of applications is October 6, 2026 at 9:00 PM (PST). We are encouraging you to apply early. If you apply after the first review date, your application is not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date.

Our Commitment to You

Your application and resume will be reviewed by a dedicated recruiter to this position. If your experience matches what we need, we will reach out to you to discuss the next steps. The selection process may include, but is not limited to, a skills assessment, phone screen and interview.

If you make it through the steps above and are selected for this exciting role, you will be required to undergo a reference and a background check (to include a conviction record) and if applicable also pass a drug screening and/or a post-offer pre-employment medical examination (for specific positions) If you are an Internal CalOptima Health applicant, please apply through the internal portal on InfoNet.

We will make sure to keep you updated through each step of the process on your candidate portal. Please make sure to watch for updates on your candidate portal and you emails which will be sent to the email address you listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process.

Advertised: 23 Sep 2026 Pacific Daylight Time
Applications close: 23 Oct 2026 Pacific Daylight Time

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