Remote Episodic Care Manager - Clinical Review

Blue Cross and Blue Shield of North Carolina; Durham (NC); Hybrid; USD 74.000 - 118.000; Vollzeit

Benefits dieser Stelle

Medical benefits

Dental benefits

Vision benefits

Parental leave

Tuition reimbursement

401k match

Zusammenfassung

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.

Qualifikationen

• 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).

Aufgaben

• 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.

Kenntnisse

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

Jobbeschreibung

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.