Overview
On Site
35/hr - 39/hr
Full Time
Skills
LPN
Evaluation
Policies
Regulatory Compliance
Collaboration
Documentation
MDS
Job Details
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.
** 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.
Contract Duration: 6+ Months
Required Skills & Experience
What You Will Be Doing
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
** 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.
Contract Duration: 6+ Months
Required Skills & Experience
- RN with 3 years of clinical experience or LPN with 5 years of clinical experience or LCSW with 3 years of clinical experience or LPC with 3 years of experience or other applicable Behavioral Health clinical licenses with 3 years of experience.
- BCBA credentials required.
- Must have and maintain a valid and applicable clinical license (NC or compact multi-state licensure) to perform described job duties.
What You Will Be Doing
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