Episodic Care Manager

🔥 0 minutes ago

🏈 Alabama, Arizona, +23 more states – Remote

🏈 Alabama – Remote 🌵 Arizona – Remote ⛰️ Colorado – Remote 🐊 Florida – Remote 🥔 Idaho – Remote 🌾 Iowa – Remote 🌪️ Kansas – Remote 🐎 Kentucky – Remote ⚜️ Louisiana – Remote 🌲 North Carolina – Remote 🏈 Ohio – Remote 🌪️ Oklahoma – Remote 🦀 Maryland – Remote 🚗 Michigan – Remote 🎸 Mississippi – Remote 🏰 Missouri – Remote 🔔 Pennsylvania – Remote 🌴 South Carolina – Remote 🗿 South Dakota – Remote 🎸 Tennessee – Remote 🤠 Texas – Remote ⛷️ Utah – Remote ⚔️ Virginia – Remote 🧀 Wisconsin – Remote 🦬 Wyoming – Remote

💵 $73.7k - $117.9k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

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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 to assess, facilitate, and coordinate delivery of health care services based on medical necessity and contractual benefits • Coordinate with providers, members, and internal staff to support high-quality, cost-effective care • Receive assigned cases for inpatient, outpatient, DME, and other member services • Review 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 required notifications to members and/or providers • Assess cases for secondary review by the Medical Director and coordinate as needed • Coordinate peer-to-peer reviews upon provider request when applicable • Collaborate with internal and external clinical and non-clinical staff, including Medical Directors • Document review outcomes and 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 roles, applicable alternative licensure may be considered with at least 3 years of clinical experience • Must have and maintain a valid, applicable clinical license in North Carolina 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 experience is a plus • Authorization to work in the United States

🏖️ 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 • Paid Time Off (PTO) • Competitive health benefits • Reasonable accommodations for applicants with disabilities