Job Description

The Episodic Care Manager- Medicare Advantage is responsible for performing clinical reviews to assess, facilitate, and coordinate the delivery of health care services for members based on medical necessity and contractual benefits. Effectively coordinate with providers, members, and internal staff to support the delivery of high quality and cost-effective care across the health care system.

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 standardsProvide 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 workAppropriately and fully document outcome of reviews and demonstrate the ability to interpret and analyze clinical informationUtilize detailed clinical knowledge to summarize clinical review against the criteria/guidelines to provide necessary information for MDs.
 

Hiring Requirements

LCSW 3 years of clinical experienceFor Behavioral Health specific roles, other applicable licensure may be considered with a minimum of 3 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.

Nice to haves

Proficient in Microsoft OfficeMedicare and Medicaid experience preferredStrong Behavioral Health SkillsUtilization Management Experience

Salary Range

At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets,  licensure and certifications and other business and organizational needs. Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs. 

*Based on annual corporate goal achievement and individual performance.
 

$61,900.00 - $99,000.00