Episodic Care Manager

Role Overview

• Perform clinical reviews to assess, facilitate, and coordinate the delivery of health care services for members based on medical necessity and contractual benefits.
• Effectively coordinate with providers, members, and internal staff to support the delivery of high quality and cost-effective care across the health care system.
• Review and evaluate cases for medical necessity against medical policy, benefits and/or care guidelines and regulations.
• Complete work in accordance with timeliness, production, clinical quality/accuracy and compliance standards.
• Provide notifications to member and/or provider, according to regulatory requirements.
• Assess appropriateness for secondary case review by the Medical Director (MD) for denials and coordinate as needed.
• May coordinate peer-to-peer review upon provider request when members’ health conditions do not meet guidelines.

Requirements

• RN with 3 years of clinical experience or LPN with 5 years of clinical experience.
• For Behavioral Health specific roles, other applicable licensure may be considered with a minimum of 3 years of clinical experience.
• Must have and maintain a valid and applicable clinical license (NC or compact multi-state licensure) to perform described job duties.

Benefits

• Work-life balance, flexibility, and the autonomy to do great work
• Medical, dental, and vision coverage along with numerous health and wellness programs
• Parental leave and support plus adoption and surrogacy assistance
• Career development programs and tuition reimbursement for continued education
• 401k match