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
Collaboration and Documentation
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.
What You Bring
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.
What You'll Get
The opportunity to work at the cutting edge of health care delivery with a team that's deeply invested in the community
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
Where You'll Work
Our Hybrid Flex approach is built on presence with a purpose - giving you flexibility to work remotely with intentional in-person connection - that supports a workplace that's flexible, connected, and future focused.
In a Hybrid-Flex role, you'll work in the office at least two days a week for collaboration and connection. In a Remote Flex role, you'll work virtually, with a few in-office visits each year for meaningful moments that matter.
Whether your role is Hybrid Flex or Remote Flex depends on the nature of the work and distance from our Durham headquarters. We welcome candidates from outside the local area and in any states listed on this job posting. Onsite expectations will be discussed during the interview process.
Salary Range
*Based on annual corporate goal achievement and individual performance.
$73,698.00 - $117,917.00
Benefits
Health insuranceDental insuranceVision insurance401(k)Paid time offRemote work optionsFlexible schedulePerformance bonusParental leave
Additional Information
Job Description
We're hiring an Episodic Case Manager to join the Medicare Utilization Management Team! 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. Effectively coordinate with providers, members, and internal staff to support the delivery of high quality and cost-effective care across the health care system.
Bcbsnc · Remote