Episodic Care Manager (Multiple Positions)
About the position The Episodic Care Manager is responsible for performing clinical reviews to assess, facilitate, and coordinate the delivery of health care services for members based on medical necessity and contractual benefits. This role involves effective coordination with providers, members, and internal staff to ensure high-quality and cost-effective care across the health care system. Responsibilities Receive assigned cases for varied member services (i.e. inpatient, outpatient, DME) , 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 , Communicate and collaborate effectively with internal and external clinical/non-clinical staff (including MDs) to coordinate work , Appropriately and fully document outcome of reviews and demonstrate the ability to interpret and analyze clinical information , Utilize detailed clinical knowledge to summarize clinical review against the criteria/guidelines to provide necessary information for MDs. 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. Nice-to-haves Benefits Annual Incentive Bonus , 401(k) with employer match , Paid Time Off (PTO) , Competitive health benefits , Wellness programs Apply Job!