Episodic Care Manager at Blue Cross and Blue Shield of North Carolina in Durham, North Carolina

Posted in Management 5 days ago.

Job Description:

The majority of our roles will continue working from home through September. Once campus restrictions begin easing in October, we will continue to encourage employees to take a virtual-first approach to their work when possible. As long as job responsibilities are not impacted, being in the office full-time will not be necessary or expected. During the interview process, our Talent Advisors will walk through our virtual-first approach and will answer questions you may have.

Additional Locations:

Job Description

The Episodic Care Manager is responsible for performing medical 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.

Clinical Evaluation and Review

  • Receive assigned cases (through service form or task list) 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 members' plan of care to optimal levels

  • Facilitate ongoing information exchange among individuals involved with the care of the member such as the Primary Care Provider (PCP), managing physician, caregivers, community resources, or other ancillary services.

  • Identify, assess and facilitate discharge planning needs and case management, behavioral health or disease management referrals.

  • Consult with MDs to make recommendations for alternative settings of care when appropriate.

  • May partner with providers in onsite capacity as needed to act as a liaison between members and internal and external case management/discharge planning.


  • 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.

Hiring Requirements

  • RN with three (3) years of previous clinical nursing experience OR LPN with five (5) years of previous clinical nursing experience.
  • Proficiency with a Microsoft Windows operating system
  • Must have valid license to practice nursing within the US and have started application for NC nursing license.