Episodic Care Manager


Durham, North Carolina

12 days ago

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Episodic Care Manager
Durham, North Carolina

12 days ago

Job Description

Job Title: Episodic Care Manager
Duration: 4 Months with a possibility of extension or conversion based on the business needs.
Location: The role is 100% remote, but candidates need to be from an approved conversion State list: (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.)
Training: 4 to 6 weeks M-F from 8 a.m. to 5 p.m. EST (Resources can't have any absences during training)
Shift Timings: The hours are 8 a.m. to 5 p.m., not OT is expected??. 
This team supports 7 days a week and at least 1 weekend day weekly will be required (preferably both weekend days). Weekend support is necessary to keep the volume and aging cases down to align with CMS (Center for Medicare Services) guidelines.

This role is to support medical neccesity for review within Medicare guidelines.
Candidates need to have prior authorization experience.
SLA is 15 cases completed daily
Standard Medical Necessity reviews have a 14 days SLA and expedited reviews have a 72 hours SLA.
Experience with Medicare, Case Utilization, and Care Radius is a plus


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 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.
•    Must have and maintain a valid and applicable clinical license (NC or compact multi-state licensure) to perform described job duties.


About Us: Established in 2004, SPECTRAFORCE® is one of the largest and fastest-growing diversity-owned staffing firms in the US. The growth of our company is a direct result of our global client service delivery model that is powered by our state-of-the-art A.I. proprietary talent acquisition platform, robust ISO 9001:2015/ISO 27001 certified processes, and strong and passionate client engaged teams. We have built our business by providing talent and project-based solutions, including Contingent, Permanent, and Statement of Work (SOW) services to over 140 clients in the US, Canada, Puerto Rico, Costa Rica, and India. Key industries that we service include Technology, Financial Services, Life Sciences, Healthcare, Telecom, Retail, Utilities and Transportation. SPECTRAFORCE is built on a concept of “human connection,” defined by our branding attitude of NEWJOBPHORIA®, which is the excitement of bringing joy and freedom to the work lifestyle so our people and clients can reach their highest potential. Learn more at: http://www.spectraforce.com
Benefits: SPECTRAFORCE offers ACA compliant health benefits as well as dental, vision, accident, critical illness, voluntary life, and hospital indemnity insurances to eligible employees. Additional benefits offered to eligible employees include commuter benefits, 401K plan with matching, and a referral bonus program. SPECTRAFORCE provides unpaid leave as well as paid sick leave when required by law.

Equal Opportunity Employer: SPECTRAFORCE is an equal opportunity employer and does not discriminate against any employee or applicant for employment because of race, religion, color, sex, national origin, age, sexual orientation, gender identity, genetic information, disability or veteran status, or any other category protected by applicable federal, state, or local laws. Please contact Human Resources at LOA@spectraforce.com if you require reasonable accommodation. 
At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position’s starting pay is: $42.43/hr.

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