Episodic Care Manager

E-Verify Program

Episodic Care Manager responsible for clinical reviews and coordinating health care services. Join a team at Blue Cross NC dedicated to high quality and cost-effective care.

Posted 6/10/2026full-timeDurham • North Carolina • 🇺🇸 United StatesMid-LevelSenior💰 $73,698 - $117,917 per yearWebsite

About the role

Key responsibilities & impact

Perform 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.
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.

Requirements

What you’ll need

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.

Benefits

Comp & perks

Work-life balance, flexibility, and the autonomy to do great work
Medical, dental, and vision coverage along with numerous health and wellness programs
Parental leave and support plus adoption and surrogacy assistance
Career development programs and tuition reimbursement for continued education
401k match

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

clinical reviewsmedical necessity assessmentcase evaluationcare coordinationregulatory compliancepeer-to-peer reviewclinical quality assessment

Soft Skills

communicationcoordinationinterpersonal skillsorganizational skills

Certifications

RN licenseLPN licenseNC licensurecompact multi-state licensure