Episodic Care Manager Overview • The Episodic Care Manager role involves clinical evaluation and review to ensure optimal patient care and adherence to guidelines. • Conduct assessments for medical necessity against policies, benefits, and care regulations. • Coordinate secondary case reviews with Medical Directors for complex cases. • Provide timely notifications to members and providers as per regulatory requirements. • Collaborate with internal and external teams to ensure seamless case management. • Document clinical review outcomes comprehensively and accurately. • Utilize clinical expertise to summarize reviews and support decision-making processes. • Work remotely in a dynamic and supportive environment with potential for contract extension. Episodic Care Manager Key Responsibilities & Duties • Review assigned cases involving inpatient, outpatient, and durable medical equipment services. • Evaluate cases for medical necessity and compliance with clinical guidelines. • Coordinate peer-to-peer reviews upon provider requests for complex health conditions. • Communicate effectively with clinical and non-clinical staff to ensure coordinated care. • Document review outcomes and interpret clinical information accurately. • Summarize clinical reviews against established criteria for Medical Director evaluations. • Ensure compliance with production, quality, and timeliness standards. • Maintain adherence to regulatory requirements in all communications and notifications. Episodic Care Manager Job Requirements • Registered Nurse (RN) with 3+ years of clinical experience or Licensed Practical Nurse (LPN) with 5+ years. • Behavioral Health licensure considered with minimum 3 years of clinical experience. • Bachelor of Arts (BA) degree required for eligibility. • Valid clinical license (NC or compact multi-state) mandatory for job duties. • Proficiency in medical policy evaluation and clinical documentation. • Strong collaboration skills with internal and external stakeholders. • Ability to analyze and interpret clinical information effectively. • Experience in remote work environments preferred.