Episodic Care Manager

Piper Companies is seeking an Episodic Care Manager to join a leading health insurance and managed care organization for a remote contract position based in North Carolina. The Episodic Care Manager will support utilization management operations by reviewing clinical service requests, evaluating medical necessities, and collaborating with providers and internal healthcare teams to ensure appropriate care decisions and regulatory compliance. The Episodic Care Manager will serve as a key clinical resource for authorization reviews and care coordination activities.

Responsibilities of the Episodic Care Manager include: · Conduct clinical reviews for inpatient, outpatient, and specialty healthcare services to determine coverage eligibility based on established guidelines and benefit plans. · Analyze medical records and supporting documentation to assess medical necessities and ensure adherence to utilization management standards. · Communicate authorization determinations and required follow-up actions to providers, members, and healthcare stakeholders. · Prepare comprehensive clinical summaries and documentation for escalated reviews, including cases requiring physician involvement. · Collaborate with medical directors and healthcare professionals to facilitate peer-to-peer discussions and support effective case resolution.

Qualifications for the Episodic Care Manager include: · Active RN license with a minimum of 3 years of clinical experience preferred; LPN candidates with 5+ years of clinical experience will also be considered. · Current North Carolina RN License or Compact RN License required. · Prior telephonic utilization review or utilization management experience within a health insurance company or managed care organization. · Experience reviewing Medicare and/or Medicaid cases; Behavioral Health, Adolescent Behavioral Health, or Eating Disorder review experience is highly preferred. · Strong clinical assessment, medical necessity review, documentation, and communication skills.

Compensation for the Episodic Care Manager: · Hourly Rate: $25-$35 an hour · Comprehensive Benefits: Medical, Dental, Vision, sick leave if required by law, and 401K

This job opens for applications on 9/4/26. Applications for this job will be accepted for at least 30 days from the posting date.

Keywords: utilization review, utilization management, medical necessity, prior authorization, episodic care management, managed care, health insurance, Medicare, Medicaid, behavioral health, adolescent behavioral health, eating disorders, clinical review, care coordination, authorization review, inpatient review, outpatient review, DME, peer-to-peer review, clinical documentation, compliance, nursing, registered nurse, RN, LPN, medical policy, healthcare operations, telephonic review, clinical assessment, case management, managed healthcare.

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