Episodic Care Manager - Behavioral Health Autism Services

📋 Description

• • As an Episodic Care Manager within the Behavioral Health Team at Blue Cross and Blue Shield of North Carolina, you will play a pivotal role in ensuring members receive high-quality, cost-effective healthcare services, with a specialized focus on Autism Services.
• • Your primary responsibility will be to conduct thorough clinical reviews, meticulously assessing the medical necessity of proposed treatments and services against established medical policies, contractual benefits, and regulatory guidelines.
• • This involves evaluating a diverse range of member services, including inpatient care, outpatient treatments, and durable medical equipment (DME), ensuring each case aligns with established standards.
• • You will be instrumental in facilitating and coordinating the delivery of these healthcare services, acting as a crucial link between members, providers, and internal stakeholders.
• • A key aspect of your role will be to maintain rigorous adherence to all performance metrics, including timeliness, production targets, clinical quality, accuracy, and compliance standards, ensuring efficient and effective case management.
• • You will be responsible for communicating critical information to members and providers, ensuring they are fully informed about service approvals, denials, and any required actions, in strict accordance with all regulatory mandates.
• • A significant part of your duty involves assessing cases for potential escalation to a Medical Director (MD) for further review, particularly in instances where services may not meet initial medical necessity criteria, and coordinating these reviews seamlessly.
• • For cases where a provider requests a peer-to-peer review due to a member's health condition not meeting established guidelines, you will facilitate this process, ensuring open communication and a thorough clinical exchange.
• • Effective and clear communication and collaboration are paramount; you will engage regularly with a wide array of internal and external clinical and non-clinical staff, including Medical Directors, to ensure coordinated and optimal care delivery.
• • You will meticulously document the outcomes of all reviews, demonstrating a sophisticated ability to interpret complex clinical information and translate it into clear, concise summaries that support decision-making processes.
• • Your deep clinical knowledge will be leveraged to analyze and summarize clinical information against established criteria and guidelines, providing essential insights for Medical Directors.
• • This role requires a proactive approach to care coordination, aiming to optimize patient outcomes while managing healthcare resources efficiently.
• • You will contribute to a culture of continuous improvement by identifying potential areas for process enhancement within the care management workflow.
• • By ensuring that care aligns with medical necessity and benefits, you directly impact the member's experience and the overall effectiveness of the healthcare system.
• • The remote nature of this position offers flexibility, allowing you to contribute significantly to member well-being from a location that suits you within North Carolina.
• • You will be part of a dedicated Behavioral Health Team, contributing to the company's mission of improving the health and well-being of its members.
• • This role provides a unique opportunity to work at the forefront of healthcare delivery, focusing on specialized behavioral health needs within the autism spectrum community.
• • Your expertise will help navigate the complexities of the healthcare system for members, ensuring they access the appropriate level of care.
• • You will be a key player in managing episodic care, ensuring that transitions between different levels of care are smooth and well-supported.
• • The ability to interpret and apply complex clinical guidelines and policies is central to success in this role, ensuring consistent and fair decision-making.
• • You will contribute to the financial stewardship of the healthcare system by ensuring that services provided are medically necessary and aligned with member benefits.
• • This position demands a high level of organizational skill and attention to detail to manage a caseload effectively and meet all deadlines.
• • You will be empowered to make informed decisions based on clinical evidence and established protocols, contributing to the overall success of the care management program.
• • The role requires a commitment to ethical practice and patient advocacy, ensuring that members' needs are met with compassion and professionalism.
• • You will be an integral part of a team dedicated to making a tangible difference in the lives of individuals and families navigating behavioral health challenges.
• • This position offers a chance to deepen your expertise in behavioral health and autism services within a leading healthcare organization.
• • Your work will directly support Blue Cross NC's commitment to providing accessible and comprehensive healthcare solutions.
• • You will be expected to stay current with evolving clinical best practices and regulatory changes relevant to behavioral health and autism services.
• • The ability to work independently and manage your time effectively in a remote setting is crucial for success.
• • You will be a point of contact for complex cases, requiring strong problem-solving skills and a thorough understanding of the healthcare landscape.
• • This role is essential in bridging the gap between clinical needs and the administrative processes of healthcare delivery.
• • You will contribute to data collection and reporting efforts related to care management activities, providing valuable insights into service utilization and outcomes.
• • The ultimate goal is to enhance the member experience by ensuring timely, appropriate, and effective behavioral health services, particularly for those on the autism spectrum.