Episodic Care Manager - 171209

Responsibilities: Perform clinical assessments for inpatient, outpatient, durable medical equipment (DME), and other healthcare service requests to determine coverage appropriateness. Apply medical policies, benefit plans, regulatory guidelines, and evidence-based criteria when reviewing cases for authorization and utilization management decisions. Coordinate with physicians, nurses, providers, and operational teams to ensure timely resolution of clinical reviews and authorization requests. Prepare detailed case documentation, clinical summaries, and review outcomes while maintaining compliance with productivity, quality, and regulatory expectations. Escalate complex cases for physician review, facilitate peer-to-peer discussions when appropriate, and communicate determination outcomes to members and providers. Qualifications: Active Registered Nurse (RN) license with at least three years of clinical experience, or Licensed Practical Nurse (LPN) license with a minimum of five years of clinical experience. Valid North Carolina nursing license or active compact multistate nursing license required throughout employment. Strong understanding of utilization management, medical necessity review, health plan benefits, and healthcare regulations. Proven ability to analyze clinical records, interpret guidelines, and present concise clinical assessments for physician review. Excellent communication, organizational, and documentation skills with experience working independently in a remote environment. Compensation: Salary Range: $65,000 - $80,000 annually Comprehensive Benefits: Medical, Dental, Vision, sick leave if required by law, and 401K Application Details Posting Date: August 7, 2026 Apply By Date: August 31, 2026 Work Arrangement: Fully Remote Employment Type: Long-Term Contract