Remote Episodic Care Manager | Utilization & Authorization

ZP Group; North Carolina; Remote; USD 65,000 - 80,000; Full time

Job summary

Piper Companies is seeking an Episodic Care Manager for a fully remote opportunity within the healthcare and managed care industry.

This Episodic Care Manager position is a long-term contract role responsible for conducting utilization reviews, evaluating medical necessity, coordinating clinical determinations, and collaborating with providers and internal healthcare teams to support quality member outcomes.

Qualifications

• Active RN license with at least 3 years of clinical experience, or LPN license with at least 5 years.
• NC nursing license or active compact multistate license required throughout employment.
• Strong understanding of utilization management and medical necessity review.
• Ability to analyze clinical records and present concise assessments for physician review.
• Excellent communication, organizational, and documentation skills; remote work experience.

Responsibilities

• Perform clinical assessments for inpatient, outpatient, DME, and other service requests to determine coverage appropriateness.
• Apply medical policies, benefit plans, regulatory guidelines, and evidence-based criteria when reviewing cases for authorization and utilization decisions.
• Coordinate with physicians, nurses, providers, and operational teams to ensure timely resolution of clinical reviews and authorization requests.
• Prepare detailed case documentation, clinical summaries, and review outcomes while maintaining compliance with productivity, quality, and regulatory expectations.
• Escalate complex cases for physician review, facilitate peer-to-peer discussions, and communicate determination outcomes to members and providers.

Skills

RN license

LPN license

Remote work

Utilization management

Medical necessity

Job description

Piper Companies is seeking an Episodic Care Manager for a fully remote opportunity within the healthcare and managed care industry.

This Episodic Care Manager position is a long-term contract role responsible for conducting utilization reviews, evaluating medical necessity, coordinating clinical determinations, and collaborating with providers and internal healthcare teams to support quality member outcomes.