Episodic Care Manager

Job Details

Job DescriptionThe 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 staffto support the delivery of high quality and cost-effective care across the health care system.What You'll DoClinical Evaluation and ReviewReceive 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 DocumentationCommunicate 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'll Bring (Hiring 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.Salary Range$61,900.00 - $99,000.00About UsIt's an exciting time to work at Blue Cross and Blue Shield of North Carolina (Blue Cross NC). Health care is changing, and we're leading the way. We offer more than health insurance our customers can count on. Were committed to better health and better health care in our communities and beyond. Our employees bring energy and creativity to the workplace, and it shows in our innovative approach to improving the health and well-being of North Carolinians.Blue Cross NC is a fully taxed, not-for-profit company headquartered in Durham, North Carolina. We serve more than 4.3 million members, and we employ more than 5,000 people across the country who are passionate about making health care better for all.Help us lead the charge for better health care by joining our award-winning team. Discover tremendous opportunities with us to do challenging and rewarding work. Opportunities that can lead you to a fulfilling career, work that can help others lead healthier, happier lives.Authorization to Work in the United StatesWe use E-verify to confirm authorization to work in the United States. To learn more about E-Verify, including your rights and responsibilities, please visit E-Verify Overview ( for English or Visin General de E-Verify ( for Espaol.For most roles, you can choose where to work - fully remote in one of the states listed below, in the office, or a hybrid of the two:Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and WyomingMuch more than a paycheckThe total value of working at Blue Cross NC goes far beyond your paycheck. We offer benefits and perks ( that help you thrive, such as competitive health benefits, bonus plans based on performance, 401(k) with employer match, paid time off (plus two well-being days), and a variety of career development and wellness programs.

 BlueCross BlueShield of North Carolina

 07/05/2024

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