Episodic Care Manager - Medicare Advantage at Blue Cross and Blue Shield of North Carolina

Job DescriptionThe 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.What You'll DoClinical Evaluation and ReviewReceive 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 regulationsComplete work in accordance with timeliness, production, clinical quality/accuracy and compliance standardsProvide notifications to member and/or provider, according to regulatory requirementsAssess appropriateness for secondary case review by the Medical Director (MD) for denials and coordinate as neededMay coordinate peer-to-peer review upon provider request when members' health conditions do not meet guidelinesCollaboration and DocumentationCommunicate and collaborate effectively with internal and external clinical/non-clinical staff (including MDs) to coordinate workAppropriately and fully document outcome of reviews and demonstrate the ability to interpret and analyze clinical informationUtilize detailed clinical knowledge to summarize clinical review against the criteria/guidelines to provide necessary information for MDsWhat You'll BringRN with 3 years of clinical experience or LPN with 5 years of clinical experienceMust have and maintain a valid and applicable clinical license (NC or compact multi-state licensure) to perform described job dutiesWhat You'll GetThe opportunity to work at the cutting edge of health care delivery with a team that's deeply invested in the communityWork-life balance, flexibility, and the autonomy to do great workMedical, dental, and vision coverage along with numerous health and wellness programsParental leave and support plus adoption and surrogacy assistanceCareer development programs and tuition reimbursement for continued education401k match including an annual company contributionLearn moreSalary RangeAt 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 - $117,917.00Skills