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Blue Cross NC · 3 hours ago

Episodic Care Manager - Behavioral Health

United States

Full-time

Remote

Mid Level

$74K/yr - $118K/yr

3+ years exp

Blue Cross NC is seeking an Episodic Care Manager to join their Behavioral Health Team. The role involves performing clinical reviews to assess, facilitate, and coordinate the delivery of health care services for members, ensuring high quality and cost-effective care across the health care system.

Financial ServicesHealth InsuranceInsurance

Comp. & Benefits

H1B Sponsor Likely

Responsibilities

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

Qualification

Clinical ExperienceClinical ReviewClinical AnalysisClinical Documentation ReviewMedical ReviewMedical CarePatient CarePatient EvaluationsMedical InformationMedicareClinical KnowledgeClinical EvaluationsDecision Making

Required

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

Preferred

Previous experience with utilization management in Behavioral Health strongly preferred

Benefits

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 including an annual company contribution

Company

Blue Cross NC

Glassdoor4.1

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.

Founded in 1933

Durham, North Carolina, USA

5001-10000 employees

https://www.bluecrossnc.com/

H1B Sponsorship

Blue Cross NC has a track record of offering H1B sponsorships. Please note that this does not guarantee sponsorship for this specific role. Below presents additional info for your reference. (Data Powered by US Department of Labor)

Distribution of Different Job Fields Receiving Sponsorship

Represents job field similar to this job

Trends of Total Sponsorships

2025 (4)

2024 (1)

2023 (2)

2022 (5)

2021 (13)

2020 (5)