Title: Episodic Care Manager
Duration: 6 months (Contract)
Location: Remote, must be located in any one of the following states (North Carolina,Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming.)
Shift: EST time zone
BCBA credentials required.
Must have and maintain a valid and applicable clinical license (NC or compact multi-state licensure) to perform described job duties.
PPA outpatient procedures.
Clinical Evaluation and Review
• Receive assigned cases for varied member services (i.e. inpatient, outpatient, DME)
• Review and evaluate cases for medical necessity against medical policy, benefits and/or care guidelines and regulations.
• Complete work in accordance with timeliness, production, clinical quality/accuracy and compliance standards
• Provide notifications to member and/or provider, according to regulatory requirements.
• Assess appropriateness for secondary case review by the Medical Director (MD) for denials and coordinate as needed.
• May coordinate peer-to-peer review upon provider request when members’ health conditions do not meet guidelines
Collaboration and Documentation
• Communicate and collaborate effectively with internal and external clinical/non-clinical staff (including MDs) to coordinate work
• Appropriately and fully document the outcome of reviews and demonstrate the ability to interpret and analyze clinical information
• Utilize detailed clinical knowledge to summarize clinical review against the criteria/guidelines to provide necessary information for MDs.
Hiring Requirements
• RN with 3 years of clinical experience or LPN with 5 years of clinical experience or LCSW with 3 years of clinical experience or LPC with 3 years of experience or other applicable Behavioral Health clinical licenses with 3 years of experience.