Social work case manager • durham nc
North Carolina, Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Pennsylvania, S... Show more
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The average salary range is between $ 44,310 and $ 83,710 year , with the average salary hovering around $ 57,917 year .
% Remote - ONLY states
North Carolina, Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming will be allowed to maintain their current residence and work remotely.
Please upload license(s).
. Required Skills: Computer Skills, Telephonic
. Nice to have Skills: Social worker utilization review (using MCG or internal policy that an insurance company would use for their review) prior off review, Skilled home health background
. Years of Experience: - years of experience. If they have not done managed care they need more years of experience
. Education/Certifications Required: Cert Case Manager
. Industry Specific Experience – required, ideal, necessary? Medicare, Home Health
. What is this role’s main focus for the st days? Breakdown of Duties/Typical Day: Provider facing (ineracting with providers if they need to get additional information to review a case). Reviewing cases for medicial necessity and making authorization determination. Will log into the system to work cases throughout the day this will be specifically for Home Health. Will be doing all levels of care. Basically is the one deciding if BCBSNC will be the one to pay for the service
Clinical Evaluation and Review
• Receive assigned cases for varied member services ( 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
Collaboration and Documentation
• 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.
Hiring Requirements
• RN with years of clinical experience or LPN with years of clinical experience.
• For Behavioral Health specific roles, other applicable licensure may be considered with a minimum of 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.
