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.

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 (. 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

You will receive the following benefits :

• Medical Insurance - Four medical plans to choose from for you and your family
• Dental & Orthodontia Benefits
• Vision Benefits
• Health Savings Account (HSA)
• Health and Dependent Care Flexible Spending Accounts
• Voluntary Life Insurance, Long-Term & Short-Term Disability Insurance
• Hospital Indemnity Insurance
• 401(k) including match with pre and post-tax options
• Paid Sick Time Leave
• Legal and Identity Protection Plans
• Pre-tax Commuter Benefit
• 529 College Saver Plan
30+ days ago