Title: Episodic Care Manager
Duration: 6 Months
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)
Shift hours : M-F 8-5 Will work 1 weekend day (saturday or sunday) .
Hours are Eastern Time hours (8 or 10 hour shift available)
During Traing M-F 8-5
No OT - will have 1 day off during the week 

Skills:

• Communication skills
• Case management skills
• Insurance background a plus
• Understanding medicare is a plus
• Computer skills a must,  all documentation is on line
• MS Office
• Care radius and Facets software ( all day everyday)

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.
• For Behavioral Health specific roles, other applicable licensure may be considered with a minimum of 3 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.

 

 


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: $40.98/hr.