Remote Episodic Care Manager - Utilization & Review

Zachary Piper Solutions; United States; Remote; USD 34,000 - 48,000; Full time

Benefits offered by this job

Medical benefits

Dental benefits

Vision benefits

Sick leave

401K

Job summary

Piper Companies is seeking an Episodic Care Manager to support utilization management for a remote contract role based in the United States. The role involves reviewing clinical service requests, evaluating medical necessity, and coordinating with providers and internal teams to ensure compliant care decisions.

Active RN license with UR experience is preferred; NC licensure or compact authorization is required.

Qualifications

• Active RN license with a minimum of 3 years of clinical experience preferred; LPN candidates with 5+ years of clinical experience will also be considered.
• Current North Carolina RN License or Compact RN License required.
• Prior telephonic utilization review or utilization management experience within a health insurance company or managed care organization.
• Experience reviewing Medicare and/or Medicaid cases; Behavioral Health, Adolescent Behavioral Health, or Eating Disorder review experience is highly preferred.
• Strong clinical assessment, medical necessity review, documentation, and communication skills.

Responsibilities

• Conduct clinical reviews for inpatient, outpatient, and specialty services to determine coverage eligibility based on guidelines and benefit plans.
• Analyze medical records to assess medical necessities and ensure adherence to utilization management standards.
• Communicate authorization determinations and required follow-up actions to providers, members, and stakeholders.
• Prepare comprehensive clinical summaries and documentation for escalated reviews, including physician involvement where needed.
• Collaborate with medical directors and healthcare professionals to support peer-to-peer discussions and case resolution.

Skills

RN license

Utilization review experience

Care coordination

Medical policy knowledge

Communication skills

Job description

Piper Companies is seeking an Episodic Care Manager to support utilization management for a remote contract role based in the United States. The role involves reviewing clinical service requests, evaluating medical necessity, and coordinating with providers and internal teams to ensure compliant care decisions.

Active RN license with UR experience is preferred; NC licensure or compact authorization is required.