Title:Episodic Care Manager
Duration: 5 months
Shift Timings - 8-5 M-F
Location: Remote, but candidates need to be from an approved conversion state.
States 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.)


JOB DESCRIPTION:

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.

Top 3-4 Required Skills:

• RN with substance abuse Multi system capability working knowledge of outlook.
• Managed care experience.
• Reviewing cases for medical necessity and making authorization determination.
• ?Will log into the system to work cases.
• Case manager experience.

Nice to have Skills:

• Social worker

Years of Experience:

• 3-5 years of experience.
• If they have not done managed care they need more years of experience.

Education/Certifications Required:

• Licensed behavior health provider.

 
 
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: $ 38.42/hr.