Utilization Management RN – Care Coordination

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

Benefits offered by this job

Medical, dental, and vision coverage

401k with company match

Parental leave and adoption support

Tuition reimbursement

Job summary

Blue Cross NC is seeking an Episodic Care Manager to join the Medicare Utilization Management Team. You will perform clinical reviews to assess, facilitate, and coordinate care delivery based on medical necessity and benefits.

The role requires RN or LPN licensure with 3–5 years of clinical experience; you will collaborate with providers, members, and internal staff to ensure high-quality, cost-effective care across the health system.

Qualifications

• RN or LPN licensure with relevant clinical experience.
• Medical policy and regulatory knowledge required.
• Ability to interpret clinical information for reviews.

Responsibilities

• Receive assigned cases for inpatient, outpatient, DME services.
• Review cases for medical necessity against policies and benefits.
• Complete work with timeliness and quality standards.
• Provide notifications to member/provider per regulations.
• Assess need for secondary review by Medical Director.
• Coordinate peer-to-peer reviews when needed.

Skills

Clinical review

Regulatory compliance

Medical policy interpretation

Team collaboration

Education

RN license

LPN license

Tools

CareRadius

Facets

Microsoft Office

Job description

Blue Cross NC is seeking an Episodic Care Manager to join the Medicare Utilization Management Team. You will perform clinical reviews to assess, facilitate, and coordinate care delivery based on medical necessity and benefits.

The role requires RN or LPN licensure with 3–5 years of clinical experience; you will collaborate with providers, members, and internal staff to ensure high-quality, cost-effective care across the health system.