Episodic Care Manager

🔥 1 minute ago

🌲 North Carolina, South Carolina, +1 more states – Remote

🌲 North Carolina – Remote 🌴 South Carolina – Remote ⚔️ Virginia – Remote

💵 $73.7k - $117.9k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

👻 Ghost score 0%

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Blue Cross NC

WebsiteLinkedInAll Job Openings

5001 - 10000 employees

Founded 1933

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

Blue Cross NC is a health insurance provider that offers a range of health plans and services to individuals and groups. The company focuses on delivering quality healthcare coverage and improving health outcomes for its members through innovative health programs and services. Blue Cross NC is committed to enhancing access to affordable healthcare while supporting the health and wellness of the communities it serves.

📋 Description

• Perform clinical reviews for inpatient, outpatient, and DME member services • Assess cases for medical necessity against medical policy, benefits, care guidelines, and regulations • Complete work according to timeliness, production, clinical quality/accuracy, and compliance standards • Provide notifications to members and/or providers according to regulatory requirements • Assess cases for secondary review by the Medical Director for denials and coordinate as needed • Coordinate peer-to-peer reviews upon provider request when appropriate • Collaborate with internal and external clinical and non-clinical staff, including Medical Directors • Document review outcomes fully and accurately • Interpret and analyze clinical information • Summarize clinical reviews against criteria and guidelines for Medical Directors

🎯 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) • Experience using CareRadius preferred • Experience working with Facets claims systems preferred • Strong working knowledge of Microsoft Office applications preferred • Prior Utilization Management (UM) experience is a plus

🏖️ Benefits

• Work-life balance, flexibility, and autonomy • Medical, dental, and vision coverage • Health and wellness programs • Parental leave and support • Adoption and surrogacy assistance • Career development programs • Tuition reimbursement for continued education • 401k match including an annual company contribution • Annual Incentive Bonus based on annual corporate goal achievement and individual performance • Paid Time Off (PTO)