California Licensed Clinical Case Manager

Job Summary

Supporting healthcare providers and patients through telephonic assistance, the full-time California Licensed Clinical Case Manager will perform clinical reviews, manage prior authorization processes, and build strong customer relationships in a remote setting.

Key responsibilities

• Provide telephonic support to healthcare providers and conduct clinical reviews of prior authorization and appeal submissions
• Troubleshoot complex reimbursement cases and resolve escalated issues related to prior authorization denials
• Gather and analyze data for Quarterly Business Reviews and participate in customer meetings and training sessions

Required qualifications

• Associate degree and a valid Registered Nurse License in California, with a willingness to obtain additional licenses as needed
• Previous experience in the pharmacy benefit management (PBM) or healthcare industry
• At least 2 years of experience in a customer service role, preferably in a call center environment
• Competency in Microsoft Office applications, particularly Excel
• Strong analytical skills with the ability to prepare reports and document clearly