Episodic Care Manager

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

Benefits offered by this job

Hybrid work arrangement

Medical, dental, vision benefits

PTO and retirement benefits

Job summary

Blue Cross NC is seeking a Clinical Evaluation and Review professional to assess cases for medical necessity, document outcomes, and coordinate with MDs and care teams.

RN with 3 years or LPN with 5 years, and a valid NC or compact license are required; behavioral health roles may accept other licensure with 3 years of clinical experience.

Qualifications

• Clinical assessment and review of medical necessity
• Ability to document outcomes and interpret clinical information
• Collaboration with MDs and care teams to ensure compliance

Responsibilities

• Review cases for medical necessity against policy and guidelines
• Notify members/providers per regulatory requirements
• Coordinate peer-to-peer reviews and coordinate with Medical Director when needed

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

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.
• 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.
• 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) to perform described job duties.

Bonus Points (Preferred Qualifications)

• Recent hands‑on bedside nursing experience in an acute care hospital setting required. Experience may include Medical‑Surgical, ICU, Emergency Department, Pediatrics, Labor & Delivery, or other inpatient specialties.
• Direct patient care experience and a strong understanding of clinical diagnoses and treatment plans to effectively interpret medical documentation.

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

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

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.

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 or hiring process, please notify HR at [e-mail]. 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.