North Carolina Licensed Care Manager

Job Summary

To support utilization management operations, the remote Episodic Care Manager will review clinical service requests, evaluate medical necessities, and collaborate with providers and healthcare teams to ensure appropriate care decisions and regulatory compliance.

Key responsibilities

• Conduct clinical reviews for inpatient, outpatient, and specialty healthcare services to determine coverage eligibility
• Analyze medical records to assess medical necessities and ensure adherence to utilization management standards
• Communicate authorization determinations and facilitate peer-to-peer discussions with healthcare professionals

Required qualifications

• Current North Carolina RN License or Compact RN License required
• Active RN license with a minimum of 3 years of clinical experience preferred; LPN candidates with 5+ years will also be considered
• Prior telephonic utilization review or utilization management experience within a health insurance company or managed care organization
• Experience reviewing Medicare and/or Medicaid cases; Behavioral Health experience is highly preferred
• Strong clinical assessment and medical necessity review skills