Job Description

We’re hiring a Episodic Care Manager to join the Commercial 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.

Clinical Evaluation and Review

• 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.

Bonus Points (Preferred Qualifications)

• Recent hands-on bedside nursing experience in an acute care hospital setting required. Experience may include Medical-Surgical, ICU, Emergency Department, Pediatrics, Labor & Delivery, or other inpatient specialties.

• Direct patient care experience and a strong understanding of clinical diagnoses and treatment plans to effectively interpret medical documentation.

WhatYoullGet

• The opportunity to work at the cutting edge of health care delivery with a team thats 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 including an annual company contribution

WhereYoullWork

Our Hybrid Flex approach is builton presencewith a purpose giving you flexibility to work remotely with intentional in-person connection that supports a workplacethats flexible, connected, and future focused.

In a Hybrid-Flex role,youllwork in the office at least two days a week for collaboration and connection. In a Remote Flex role,youllwork 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

At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs.Our 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.

*Based on annual corporate goal achievement and individual performance.

$73,698.00 - $117,917.00

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