North Carolina Licensed Care Manager

Job Summary

To support utilization management operations, the remote contract position for a North Carolina Licensed Care Manager will review clinical service requests, evaluate medical necessities, and collaborate with 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 required follow-up actions to providers and healthcare stakeholders

Required qualifications

• Active RN license with a minimum of 3 years of clinical experience preferred; LPN candidates with 5+ years of clinical experience will also be considered
• Current North Carolina RN License or Compact RN License required
• 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 documentation skills