Episodic Care Manager

Episodic Care Manager Overview

• The Episodic Care Manager role involves clinical evaluation and review of member cases, ensuring compliance with medical policies and guidelines.
• Collaborate with clinical and non-clinical staff to coordinate care and document outcomes effectively.
• Utilize clinical expertise to assess cases for medical necessity and regulatory adherence.
• Provide notifications to members and providers in alignment with regulatory requirements.
• Coordinate peer-to-peer reviews and secondary case evaluations with Medical Directors as needed.
• Contribute to the improvement of clinical quality and compliance standards through diligent case management.
• This remote role offers flexibility and the potential for contract extension.

Episodic Care Manager Key Responsibilities & Duties

• Conduct clinical evaluations of assigned member cases, including inpatient, outpatient, and DME services.
• Review cases for medical necessity, ensuring alignment with policies, benefits, and care guidelines.
• Document review outcomes comprehensively, interpreting and analyzing clinical information effectively.
• Collaborate with internal and external staff, including Medical Directors, to coordinate care reviews.
• Provide timely notifications to members and providers, adhering to regulatory standards.
• Assess cases for secondary review by Medical Directors and facilitate necessary coordination.
• Ensure compliance with production, clinical quality, and accuracy standards in case management.

Episodic Care Manager Job Requirements

• Bachelor of Science (BS) degree and valid clinical license (NC or compact multi-state).
• Registered Nurse (RN) with 3 years of clinical experience or Licensed Practical Nurse (LPN) with 5 years.
• Behavioral Health roles may consider other licensure with a minimum of 3 years of experience.
• Strong ability to interpret and analyze clinical information against established guidelines.
• Proficiency in documenting outcomes and summarizing clinical reviews for Medical Directors.
• Effective communication and collaboration skills with clinical and non-clinical staff.
• Experience in managing compliance with regulatory requirements and clinical quality standards.