Our client, a nationally recognized and award-winning company in the health insurance vertical, has a contract opening for a Episodic Care Manager.
They have over 4 million customers and 5,000+ employees dedicated to providing innovative solutions that simplify the healthcare system, improve efficiency and outcomes while reducing costs.
Location : While the position is Remote, work from home, you must reside in North Carolina or one of the following states : Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming.
Hours : This team supports 7 days a week and at least 1 weekend day weekly will be required.
Contract Duration : 4+ Months
Required Skills & Experience
- RN with 3 years of clinical experience or LPN with 5 years of clinical experience
- Must have and maintain a valid and applicable clinical license (NC or compact multi-state licensure) to perform described job duties.
- Need to have prior authorization experience.
Desired Skills & Experience
Experience with Medicare, Case Utilization, and Care Radius is a plus
What You Will Be Doing
Daily Responsibilities
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
- Communicate and collaborate effectively with internal and external clinical / non-clinical staff (including MDs) to coordinate work
- Appropriately and fully document outcome of reviews and demonstrate the ability to interpret and analyze clinical information
- Utilize detailed clinical knowledge to summarize clinical review against the criteria / guidelines to provide necessary information for MDs.
To be eligible to contract at this client you must be able to pass a drug test and criminal background check
Episodic Care Manager
Our client, the health care industry, is seeking an episodic care manager to join their team. Prior authorization and Critical care experience. Review and evaluate cases for medical necessity against medical policy, benefits, and/or care guidelines and regulations. Prior authorization and critical c...
Episodic Care Manager
Our client, a nationally recognized and award-winning company in the health insurance vertical, has a contract opening for a Episodic Care Manager. Experience with Medicare, Case Utilization, and Care Radius is a plus. They have over 4 million customers and 5,000+ employees dedicated to providing in...
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Our client, a nationally recognized and award-winning company in the health insurance vertical, has a contract opening for a Episodic Care Manager. Experience with Medicare, Case Utilization, and Care Radius is a plus. They have over 4 million customers and 5,000+ employees dedicated to providing in...
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