Title: Episodic Care Manager
Duration: 7 months
Location: The role is 100% remote but the candidate needs to be from an approved conversion state (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: M-F 8-5 EST

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:

• Computer Skills
• Telephonic

Nice to Have Skills:

• Social worker utilization review (using MCG or internal policy that an insurance company would use for their review).
• Prior auth review.
• Skilled home health background.

Years of Experience:

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

Education/Certifications Required:

• Cert Case Manager

Industry Specific Experience – required, ideal, necessary?

• Medicare
• Home Health

Breakdown of Duties / Typical Day:

• Provider facing (interacting with providers if they need to get additional information to review a case).
• Reviewing cases for medical necessity and making authorization determination.
• Will log into the system to work cases throughout the day. This will be specifically for Home Health.
• Will be doing all levels of care.

What does the training look like for this role?:

• Dedicated behavioural trainer that will be able to help with getting the worker up to speed on process. (Month long training)

Screening Questions:

• Name your boldest action that you've taken to advocate for a patient.
• What makes you a good fit for this role?

 
 
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.