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.