Episodic Care Manager

Blue Cross and Blue Shield of North Carolina; Durham (NC); Hybrid; USD 74,000 - 118,000; Full time

Benefits offered by this job

Medical benefits

Dental benefits

Vision benefits

Parental leave

Tuition reimbursement

401k match

Job summary

Blue Cross NC is seeking an Episodic Care Manager to join the Commercial Clinical UM Team. You will perform clinical reviews to assess, facilitate, and coordinate the delivery of health care services for members based on medical necessity and contractual benefits.

This Remote Flex role requires RN with 3 years or LPN with 5 years of clinical experience and NC or compact multi-state licensure to coordinate with providers, members, and internal staff for high-quality, cost-effective care.

Qualifications

• RN with 3 years of clinical experience or LPN with 5 years of clinical experience.
• Must have and maintain a valid clinical license (NC or compact multi-state).

Responsibilities

• Perform clinical reviews to assess, facilitate and coordinate delivery of health care services based on medical necessity and contractual benefits.
• Review cases for medical necessity against policy, benefits and/or care guidelines.
• Notify members or providers as required by regulations and coordinate with the Medical Director for denials.
• Collaborate with internal/external staff and document outcomes of reviews.

Skills

Clinical Analysis

Clinical Documentation Review

Clinical Evaluations

Clinical Experience

Clinical Knowledge

Clinical Review

Decision Making

Medical Care

Medical Information

Medical Review

Medicare

Patient Care

Patient Evaluations

Job description

Episodic Care Manager### Episodic Care ManagerApply: Remote Flex - North Carolina: Remote Flex - South Carolina: Remote Flex - Ohio: Remote Flex - Virginia: Remote Flex - Tennessee: Full time: Posted Yesterday: End Date: October 30, 2026 (1 day left to apply): RQ0019711**Job Description**We’re hiring an Episodic Care Manager to join the Commercial Clinical UM Team! The 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 Do** **Clinical Evaluation and Review*** Receive 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 regulations.* Complete work in accordance with timeliness, production, clinical quality/accuracy and compliance standards* Provide notifications to member and/or provider, according to regulatory requirements.* Assess appropriateness for secondary case review by the Medical Director (MD) for denials and coordinate as needed.* May coordinate peer-to-peer review upon provider request when members’ health conditions do not meet guidelines. **Collaboration and Documentation*** Communicate and collaborate effectively with internal and external clinical/non-clinical staff (including MDs) to coordinate work* Appropriately and fully document outcome of reviews and demonstrate the ability to interpret and analyze clinical information* Utilize detailed clinical knowledge to summarize clinical review against the criteria/guidelines to provide necessary information for MDs. **What You Bring*** RN with 3 years of clinical experience or LPN with 5 years of clinical experience.* Must have and maintain a valid and applicable clinical license (NC or compact multi-state licensure) to perform described job duties.**What You’ll Get*** The opportunity to work at the cutting edge of health care delivery with a team that’s deeply invested in the community* Work-life balance, flexibility, and the autonomy to do great work* Medical, dental, and vision coverage along with numerous health and wellness programs* Parental leave and support plus adoption and surrogacy assistance* Career development programs and tuition reimbursement for continued education* 401k match including an annual company contribution* Learn more **Where You’ll Work** This role is Remote Flex. In a Remote Flex role, you’ll work virtually, with a few in-office visits each year for meaningful moments that matter. Whether your role is Hybrid Flex or Remote Flex depends on the nature of the work and distance from our Durham headquarters. We welcome candidates from outside the local area and in any states listed on this job posting. Onsite expectations will be discussed during the interview process.**Salary Range**At 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 - $117,917.00**Skills**Clinical Analysis, Clinical Documentation Review, Clinical Evaluations, Clinical Experience, Clinical Knowledge, Clinical Review, Decision Making, Medical Care, Medical Information, Medical Review, Medicare, Patient Care, Patient Evaluations\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_\\_ **JOB ALERT FRAUD:** We have become aware of scams from individuals, organizations, and internet sites claiming to represent Blue Cross and Blue Shield of North Carolina in recruitment activities in return for disclosing financial information. Our hiring process does not include text-based conversations or interviews and never requires payment or fees from job applicants. All our career opportunities are published on https://bcbsnc.wd5.myworkdayjobs.com/en-US/BCBSNC. If you have already provided your personal information that you suspect is fraudulent activity, please report it to your local authorities. Any fraudulent activity should be reported to: [e-mail].