Remote Utilization & Episodic Care Manager

Zachary Piper Solutions; North Carolina; Remote; USD 65,000 - 80,000; Full time

Job summary

Piper Companies is seeking an Episodic Care Manager for a fully remote, long-term contract role in the healthcare and managed care field. The position focuses on utilization reviews, medical necessity evaluations, and coordinating clinical determinations with providers and internal teams to support quality member outcomes.

Qualified candidates must hold an active RN license (3+ years) or an LPN license (5+ years), with NC or compact multistate license.

Qualifications

• Active RN license with 3+ years of clinical experience, or LPN license with 5+ years of clinical experience.
• NC nursing license or active compact multistate license required throughout employment.
• Strong understanding of utilization management, medical necessity review, health plan benefits, and healthcare regulations.
• Ability to analyze clinical records, interpret guidelines, and present concise clinical assessments for physician review.
• Excellent communication, organizational, and documentation skills with experience working independently in a remote environment.

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.
• 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 and communicate outcomes to members and providers.

Skills

RN/LPN License Eligibility

Utilization Management

Clinical Assessment & Documentation

Remote Work Proficiency

Communication Skills

Education

RN License (Active)

LPN License (Active)

Compact Multistate License

Job description

Piper Companies is seeking an Episodic Care Manager for a fully remote, long-term contract role in the healthcare and managed care field. The position focuses on utilization reviews, medical necessity evaluations, and coordinating clinical determinations with providers and internal teams to support quality member outcomes.

Qualified candidates must hold an active RN license (3+ years) or an LPN license (5+ years), with NC or compact multistate license.