Episodic Care Manager

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

Benefits offered by this job

Medical, dental, and vision coverage

401k match including an annual company

Tuition reimbursement

Job summary

Blue Cross and Blue Shield of North Carolina is seeking an Episodic Care Manager to join the Commercial Clinical Utilization Management team. The role focuses on clinical reviews to assess medical necessity and coordinate care with providers, members, and internal staff.

A valid NC or compact multi-state RN/LPN license is required. Hybrid Flex environment with remote work options and ongoing opportunities for professional development.

Qualifications

• RN with 3 years of clinical experience or LPN with 5 years of clinical experience.
• Must hold a valid NC or compact multi-state nursing licensure to perform described duties.
• Preferred experience in inpatient rehabilitation facility and/or skilled nursing facility (SNF).

Responsibilities

• Perform clinical reviews to assess, facilitate, and coordinate care for members. (inpatient, outpatient, DME)
• Review cases for medical necessity against policy, benefits and guidelines.
• Provide notifications to member and/or provider per regulatory requirements.
• Assess appropriateness for secondary case review by Medical Director for denials.
• Coordinate peer-to-peer review upon provider request when guidelines do not meet conditions.
• Collaborate with internal and external staff to coordinate work and document outcomes.

Skills

RN licensure

LPN licensure

Education

Registered Nurse license (RN)

Job description

Episodic Care Manager

We’re hiring an Episodic Care Manager to join the Commercial Clinical Utilization Management (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.

Bonus Points (Preferred qualifications)

• Demonstrated experience providing patient care in an inpatient rehabilitation facility and/or skilled nursing facility (SNF) setting.

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

Our Hybrid Flex approach is built on presence with a purpose - giving you flexibility to work remotely with intentional in-person connection - that supports a workplace that’s flexible, connected, and future focused. In a Hybrid-Flex role, you’ll work in the office at least two days a week for collaboration and connection. 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

$73,698.00 - $117,917.00

About Us

It's an exciting time to work at Blue Cross and Blue Shield of North Carolina (Blue Cross NC). Health care is changing, and we're leading the way. We offer more than health insurance our customers can count on. We're committed to better health and better health care - in our communities and beyond. Our employees bring energy and creativity to the workplace, and it shows in our innovative approach to improving the health and well-being of North Carolinians. Blue Cross NC is a fully taxed, not-for-profit company headquartered in Durham, North Carolina. We serve more than 4.3 million members, and we employ more than 5,000 people across the country who are passionate about making health care better for all. Help us lead the charge for better health care by joining our award-winning team. Discover tremendous opportunities with us to do challenging and rewarding work. Opportunities that can lead you to a fulfilling career, work that can help others lead healthier, happier lives.

Blue Cross NC is a Hybrid Flex company. Whether the 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 of our approved states: Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming

Authorization to Work in the United States

We use E-verify to confirm authorization to work in the United States. To learn more about E-Verify, including your rights and responsibilities, please visit E-Verify Overview for English or Visión General de E-Verify for Español.

Request Accommodations

Blue Cross NC provides reasonable accommodations to applicants with disabilities. If you need a reasonable accommodation for any part of the application, hiring process, or have technical issues that prevent you from completing your application please notify HR at [e-mail].