Episodic Care Manager

Overview

• Provide episodic care management services to members, ensuring compliance with medical policies and regulations.
• Evaluate cases for medical necessity and appropriateness against established guidelines and standards.
• Collaborate with clinical and non-clinical staff to coordinate member care effectively.
• Document clinical reviews accurately and summarize findings for medical directors.
• Perform peer-to-peer reviews upon provider request when guidelines are not met.
• Ensure timely notifications to members and providers as per regulatory requirements.
• Support secondary case reviews and coordinate with medical directors for denials.

Key Responsibilities & Duties

• Receive and manage assigned cases for varied member services, including inpatient and outpatient care.
• Evaluate cases for medical necessity and compliance with care guidelines and regulations.
• Coordinate peer-to-peer reviews and secondary case reviews as required.
• Collaborate with internal and external staff to ensure effective care management.
• Document clinical reviews comprehensively and interpret clinical information accurately.
• Provide detailed summaries of clinical reviews for medical director evaluations.
• Ensure compliance with timeliness, production, and clinical quality standards.

Job Requirements

• Registered Nurse (RN) with 3 years of clinical experience or Licensed Practical Nurse (LPN) with 5 years of clinical experience.
• Valid and applicable clinical license (NC or compact multi-state licensure).
• Bachelor of Arts (BA) degree in a relevant field.
• Experience in adolescent psychiatry and eating disorder management preferred.
• Strong clinical knowledge and ability to analyze and interpret medical information.
• Proficiency in documentation and summarization of clinical reviews.
• Excellent communication and collaboration skills with clinical and non-clinical staff.