Episodic Care Manager

Episodic Care Manager Overview

• The Episodic Care Manager role involves clinical evaluation and review of varied member services, ensuring medical necessity and compliance with guidelines.
• This position offers a remote work arrangement, providing flexibility and work-life balance for healthcare professionals.
• Utilize your clinical expertise to assess cases, collaborate with medical directors, and coordinate peer-to-peer reviews.
• Contribute to improving healthcare outcomes by effectively documenting and analyzing clinical information.
• Work within a dynamic team environment, collaborating with internal and external clinical staff.
• This contract position offers competitive hourly compensation and potential for extension based on performance.
• Ideal for professionals seeking to leverage their nursing expertise in a regulatory-compliant setting.

Episodic Care Manager Key Responsibilities & Duties

• Evaluate assigned cases for medical necessity against established policies, benefits, and care guidelines.
• Ensure timely completion of reviews while maintaining clinical accuracy and compliance standards.
• Provide notifications to members and providers in adherence to regulatory requirements.
• Coordinate secondary case reviews with the Medical Director for denials as necessary.
• Facilitate peer-to-peer reviews upon provider request for cases not meeting guidelines.
• Collaborate with clinical and non-clinical staff to ensure seamless coordination of work.
• Document outcomes of reviews comprehensively and analyze clinical information effectively.
• Summarize clinical reviews against criteria to provide necessary information for medical directors.

Episodic Care Manager Job Requirements

• Bachelor of Science in Nursing (BSN) required; RN with 3 years or LPN with 5 years of clinical experience.
• Valid and applicable clinical license (NC or compact multi-state licensure) mandatory.
• Proficiency in clinical evaluation, case documentation, and collaboration with medical professionals.
• Experience in assessing medical necessity and coordinating peer-to-peer reviews.
• Strong knowledge of healthcare regulations and compliance standards.
• Ability to analyze clinical information and summarize reviews effectively.
• Excellent communication skills for collaboration with internal and external stakeholders.
• Behavioral health licensure considered for specific roles with minimum clinical experience.