SPECTRAFORCE TECHNOLOGIES INC (www.​spectraforce.​com) is a leading Global Staffing and IT services company.​ At Spectraforce, we truly believe and practice in our core values and entrepreneurial work culture – attributes which make us unique in our industry.​ Spectraforce is one of the Top 10 fastest growing staffing companies in the nation, as listed by SIA or the past two years.​ Our success comes from our employees and our “partner for life” ethos, which has translated into a highly satisfied client base.​ Spectraforce offers staffing services to Fortune 500 clients broadly in the following areas: IT, Clinical, Scientific, Finance, Professional and Engineering.

Job Title: Episodic Care Manager

Location: Chapel Hill, NC 27517

Duration: 3 months (increments contract after every 2 months)

Note:

Immediate Start.

Job Purpose

The Episodic Care Manager is responsible for performing medical reviews to assess, facilitate, and coordinate the delivery of care across the Health Care System.  The Episodic Care Manager acts as a member advocate to promote and coordinate the delivery of quality, cost effective health care services based on medical necessity and contractual benefits.  In addition, the Episodic Care Manager coordinates with providers and consumers to support the delivery of high quality care across the health care system.  

Major Job Functions/Components

• Conducts clinical reviews based on applicable medical policy and/or medical necessity guidelines on requested services.  Communicates decision to provider and/or member, according to department protocols.
• Prepares, presents, and refers cases, as needed, to the physician medical directors (MDs) for cases reviewed and not meeting approval criteria. Facilitates physician peer-to-peer contact upon provider request when members’ health conditions do not meet guidelines.  Consults with MDs when necessary and makes recommendations for alternative settings of care when appropriate. 
• Promotes and coordinates the delivery of quality, cost effective health care services based on medical necessity per the benefit plan.
• Documents outcome of reviews and demonstrates the ability to interpret and analyze clinical information.  Utilizes detailed knowledge of clinical guidelines and policies to meet regulatory and program requirements. 
• Facilitates communication and information exchange among individuals involved with the care of the member such as PCP, Managing Physician, caregivers, or other ancillary services.
• Communicates with providers to increase provider awareness of medical criteria and policy as it relates to services requested.  Works with providers to assure effective and efficient care management.  Meets with providers, as needed.
• Coordinates care as needed for members.
• Works with members and collaborates with other members of the team to enhance member navigation and access to available services through the health care system.
• Identifies, assesses and facilitates discharge planning and needs. 
• Maintains confidentiality of all PHI in compliance with state and federal laws

Education/Experience

• RN, LPN, PA, or FNP degree with valid NC license.
• For RN, PA, or FNP, 3 years previous clinical nursing experience, preferably in a variety of clinical settings, or 2 years in a health insurance related industry such as Utilization Management processes, managing health conditions, understanding medical criteria, medical guidelines, medical policy, and NCQA and DOI regulations. 
• If LPN, 5 years previous clinical nursing experience preferably in a variety of clinical settings, or 4 years in a health insurance related industry such as Utilization Management processes, managing health conditions, understanding medical criteria, medical guidelines, medical policy, and NCQA and DOI regulations.

Additional Education/Experience Preferences

• BSN strongly preferred. 
  Computer experience including Word
• Knowledge of Microsoft Windows operating system.
• Demonstrated commitment to high quality service to all customers.
• Knowledge of medical care patterns, regulatory and governmental rules and regulations along with medical criteria and policies related to care management
• Clinical decision making skills
• Ability to embrace and accept change.
• Ability to work with an interdisciplinary team is essential.

  Department Specific Job Functions/Components

Health Coaching and Interventions:

• May provide health coaching and education to members based on their benefit plan.
• Negotiates acceptable rate for services when appropriate. 

Senior Segment:

• Performs database search, telephonic screening and assessment, documentation, and evaluation of clinical information to determine eligibility for DM Programs.

• Identifies, facilitates, and coordinates, when appropriate, community and social services resources to compliment the physician’s treatment plan.
• Demonstrates understanding of the Case Management process by consistently adhering to member privacy and confidentiality regulations, advocating for member safety and strict adherence to ethical, legal and accreditation/regulatory standards.

Thanks & Regards

Sonali Santra
Client Delivery Executive

Spectraforce Technologies Inc.

Phone No#  919 887 6786  Ext. 4094
Fax No# (919) 882 1678

Email: [email protected]
Visit us: http://www.spectraforce.com