North Carolina Licensed Care Manager
Job Summary
To support quality member outcomes, the fully remote Episodic Care Manager will conduct utilization reviews, evaluate medical necessity, and coordinate clinical determinations while collaborating with providers and internal healthcare teams on a long-term contract basis.
Key responsibilities
- Perform clinical assessments for various healthcare service requests to determine coverage appropriateness
- Apply medical policies and regulatory guidelines when reviewing cases for authorization and utilization management decisions
- Prepare detailed case documentation and communicate determination outcomes to members and providers
Required qualifications
- Active Registered Nurse (RN) license with at least three years of clinical experience, or Licensed Practical Nurse (LPN) license with a minimum of five years of clinical experience
- Valid North Carolina nursing license or active compact multistate nursing license required throughout employment
- Strong understanding of utilization management and healthcare regulations
- Proven ability to analyze clinical records and present concise clinical assessments
- Experience working independently in a remote environment
Complete Job Description
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