Episodic Care Manager

It's an exciting time to work at Blue Cross and Blue Shield of North Carolina (Blue Cross NC). Health care is changing, and we're leading the way. We offer more than health insurance our customers can count on. We’re committed to better health and better health care − in our communities and beyond. Our employees bring energy and creativity to the workplace, and it shows in our innovative approach to improving the health and well-being of North Carolinians. Blue Cross NC is a fully taxed, not-for-profit company headquartered in Durham, North Carolina. We serve more than 4.3 million members, and we employ more than 5,000 people across the country who are passionate about making health care better for all. Help us lead the charge for better health care by joining our award-winning team. Discover tremendous opportunities with us to do challenging and rewarding work. Opportunities that can lead you to a fulfilling career, work that can help others lead healthier, happier lives.

The Episodic Care Manager is responsible for performing clinical reviews to assess, facilitate, and coordinate the delivery of health care services for members based on medical necessity and contractual benefits. Effectively coordinate with providers, members, and internal staff to support the delivery of high quality and cost-effective care across the health care system.

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