North Carolina Licensed Care Manager
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Job Summary
To support the Commercial Clinical UM Team, the full-time Remote Flex Episodic Care Manager will perform clinical reviews to assess and coordinate health care services for members, ensuring compliance with medical necessity and contractual benefits.
Key responsibilities
- Conduct clinical evaluations and reviews for assigned cases, ensuring adherence to medical policies and regulations
- Collaborate with internal and external staff to coordinate care and document outcomes of reviews effectively
- Provide notifications to members and providers in accordance with regulatory requirements and facilitate peer-to-peer reviews as needed
Required qualifications
- Registered Nurse (RN) with 3 years of clinical experience or Licensed Practical Nurse (LPN) with 5 years of clinical experience
- Valid and applicable clinical license (NC or compact multi-state licensure)
- Strong clinical knowledge for evaluating and summarizing clinical reviews
- Experience in medical necessity evaluations and compliance standards
- Ability to collaborate effectively with clinical and non-clinical staff
Complete Job Description
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