Episodic Care Manager

E-Verify Program

Episodic Care Manager delivering clinical reviews based on medical necessity and contractual benefits for the Medicare Utilization Management Team. Coordinating high quality care across the healthcare system successfully.

Posted 6/19/2026full-timeNorth Carolina • 🇺🇸 United StatesMid-LevelSenior💰 $73,698 - $117,917 per yearWebsite

About the role

Key responsibilities & impact

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
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.

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 evaluationmedical necessity reviewcase managementclinical documentationclinical analysispeer-to-peer reviewregulatory compliancecare guidelines assessmentclinical knowledge utilizationoutcome documentation

Soft Skills

communicationcollaborationinterpersonal skillsorganizational skillsanalytical skillstimelinessattention to detailproblem-solvingcoordinationclinical quality assurance

Certifications

Registered Nurse (RN)Licensed Practical Nurse (LPN)NC or compact multi-state licensure