Episodic Care Manager

Responsibilities

• Conduct clinical reviews for inpatient, outpatient, and specialty healthcare services to determine coverage eligibility based on established guidelines and benefit plans.
• Analyze medical records and supporting documentation to assess medical necessities and ensure adherence to utilization management standards.
• Communicate authorization determinations and required follow-up actions to providers, members, and healthcare stakeholders.
• Prepare comprehensive clinical summaries and documentation for escalated reviews, including cases requiring physician involvement.
• Collaborate with medical directors and healthcare professionals to facilitate peer-to-peer discussions and support effective case resolution.

Qualifications

• Active RN license with a minimum of 3 years of clinical experience preferred; LPN candidates with 5+ years of clinical experience will also be considered.
• Current North Carolina RN License or Compact RN License required.
• Prior telephonic utilization review or utilization management experience within a health insurance company or managed care organization.
• Experience reviewing Medicare and/or Medicaid cases; Behavioral Health, Adolescent Behavioral Health, or Eating Disorder review experience is highly preferred.
• Strong clinical assessment, medical necessity review, documentation, and communication skills.

Compensation and Benefits

Hourly Rate: $25-$35 an hour
Comprehensive Benefits: Medical, Dental, Vision, sick leave if required by law, and 401K