Episodic Care Manager

Overview

• Manage episodic care cases, ensuring clinical evaluation and compliance with medical policies and guidelines.
• Perform case reviews for medical necessity, coordinating with medical directors and providers as needed.
• Collaborate with clinical and non-clinical staff to ensure effective care management processes.
• Document case outcomes comprehensively, analyzing clinical information against established guidelines.
• Provide notifications to members and providers, adhering to regulatory requirements.
• Utilize clinical expertise to summarize case reviews for medical directors.
• Support peer-to-peer reviews upon provider requests for cases not meeting guidelines.
• Maintain high standards of clinical quality, accuracy, and compliance in all case evaluations.

Key Responsibilities & Duties

• Evaluate assigned cases for inpatient, outpatient, and durable medical equipment services.
• Coordinate secondary case reviews with medical directors for denial cases.
• Communicate effectively with internal and external teams, including medical directors and providers.
• Document clinical review outcomes and analyze information against care guidelines.
• Provide regulatory notifications to members and providers as required.
• Summarize clinical reviews to support decision-making by medical directors.
• Ensure compliance with timeliness, production, and accuracy standards.
• Participate in peer-to-peer reviews to address provider concerns.

Job Requirements

• Bachelor of Science in Nursing (BSN) required; valid RN or LPN license.
• Minimum of 3 years clinical experience for RNs or 5 years for LPNs.
• Applicable licensure for Behavioral Health roles with 3 years clinical experience.
• Proficiency in clinical evaluation, documentation, and regulatory compliance.
• Strong collaboration skills with clinical and non-clinical teams.
• Ability to analyze and interpret clinical information effectively.
• Experience in coordinating case reviews and peer-to-peer discussions.
• Knowledge of medical policies, benefits, and care guidelines.