Episodic Care Manager

Piper Companies is seeking an Episodic Care Manager for a fully remote opportunity within the healthcare and managed care industry. This Episodic Care Manager position is a long-term contract role responsible for conducting utilization reviews, evaluating medical necessity, coordinating clinical determinations, and collaborating with providers and internal healthcare teams to support quality member outcomes.

Responsibilities

• Perform clinical assessments for inpatient, outpatient, durable medical equipment (DME), and other healthcare service requests to determine coverage appropriateness.
• Apply medical policies, benefit plans, regulatory guidelines, and evidence-based criteria when reviewing cases for authorization and utilization management decisions.
• Coordinate with physicians, nurses, providers, and operational teams to ensure timely resolution of clinical reviews and authorization requests.
• Prepare detailed case documentation, clinical summaries, and review outcomes while maintaining compliance with productivity, quality, and regulatory expectations.
• Escalate complex cases for physician review, facilitate peer-to-peer discussions when appropriate, and communicate determination outcomes to members and providers.

Qualifications

• Active Registered Nurse (RN) license with at least three years of clinical experience, or Licensed Practical Nurse (LPN) license with a minimum of five years of clinical experience.
• Valid North Carolina nursing license or active compact multistate nursing license required throughout employment.
• Strong understanding of utilization management, medical necessity review, health plan benefits, and healthcare regulations.
• Proven ability to analyze clinical records, interpret guidelines, and present concise clinical assessments for physician review.
• Excellent communication, organizational, and documentation skills with experience working independently in a remote environment.

Compensation

Salary Range: $65,000 - $80,000 annually

Comprehensive Benefits: Medical, Dental, Vision, sick leave if required by law, and 401K

Application Details

• Posting Date: August 7, 2026
• Apply By Date: August 31, 2026
• Work Arrangement: Fully Remote
• Employment Type: Long-Term Contract

Keywords

Episodic Care Manager, Utilization Management, Medical Necessity Review, Care Management, Prior Authorization, Clinical Review, Case Management, Registered Nurse, RN, LPN, Managed Care, Health Plan Operations, Inpatient Review, Outpatient Review, DME Review, Healthcare Compliance, Clinical Documentation, Utilization Review, Clinical Assessment, Peer-to-Peer Review, Care Coordination, Appeals Management, Healthcare Regulations, NC License, Compact License, Medical Policy, Benefit Interpretation, Quality Assurance, Healthcare Operations, Member Services, Provider Relations, Clinical Decision Support, Managed Healthcare, Authorization Review, Clinical Analysis, Population Health, Remote Nursing, Health Insurance, Case Evaluation, Medical Director Review

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