Episodic Care Manager

Job Description

The Episodic Care Manager is responsible for performing clinical reviews to assess, facilitate, and coordinate the delivery of health care services for members based on medical necessity and contractual benefits. Effectively coordinate with providers, members, and internal staff to support the delivery of high quality and cost-effective care across the health care system.

What You'll Do

Clinical Evaluation and Review

• Receive assigned cases for varied member services (i.e. inpatient, outpatient, DME)
• Review and evaluate cases for medical necessity against medical policy, benefits and / or care guidelines and regulations
• Complete work in accordance with timeliness, production, clinical quality / accuracy and compliance standards
• Provide notifications to member and / or provider, according to regulatory requirements
• Assess appropriateness for secondary case review by the Medical Director (MD) for denials and coordinate as needed
• May coordinate peer-to-peer review upon provider request when members' health conditions do not meet guidelines

Collaboration and Documentation

What You'll Bring

What You'll Get

Salary Range

At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs.Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus

$73,698.00 - $117,917.00

Skills