Episodic Care Manager

About the role

The Episodic Care Manager performs clinical reviews to assess, facilitate, and coordinate the delivery of health care services for members based on medical necessity and contractual benefits. You will collaborate with providers, members, and internal staff to support high-quality, cost-effective care across the health care system.

Responsibilities

• Receive assigned cases for varied member services (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 members and/or providers according to regulatory requirements.
• Assess appropriateness for secondary case review by the Medical Director (MD) for denials and coordinate as needed.
• 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 the outcome of reviews and demonstrate the ability to interpret and analyze clinical information.
• Utilize detailed clinical knowledge to summarize clinical review against 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 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).

Preferred Qualifications

• RN with 3 years of clinical experience or LPN with 5 years of clinical experience.

Benefits

• 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 including an annual company contribution.

Pay

Salary range: $73,698.00 - $117,917.00. Starting salaries are typically planned near the middle of the range. Compensation decisions are driven by factors including experience, training, specialized skill sets, licensure, certifications, and business needs. The base salary is part of a robust Total Rewards package that includes an annual incentive bonus, 401(k) with employer match, paid time off (PTO), and competitive health benefits and wellness programs.

Schedule

Hybrid Flex approach: work in the office at least two days a week for collaboration and connection. Remote Flex roles work virtually with a few in-office visits each year. Onsite expectations will be discussed during the interview process. Candidates from outside the local area are welcome if residing in any states listed on the job posting.

Skills

• Clinical Analysis
• Clinical Documentation Review
• Clinical Evaluations
• Clinical Experience
• Clinical Knowledge
• Clinical Review
• Decision Making
• Medical Care
• Medical Information
• Medical Review
• Medicare
• Patient Care
• Patient Evaluations