North Carolina Licensed Episodic Care Manager

Job Summary

To support utilization management operations, the remote North Carolina Licensed Episodic Care Manager will conduct clinical reviews for healthcare services, evaluate medical necessities, and collaborate with providers 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 and documentation to assess medical necessities and adherence to utilization management standards
• Communicate authorization determinations and collaborate with healthcare professionals for effective case resolution

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 medical necessity review skills