We're seeking an Episodic Care Manager to join our Behavioral Health Team! The Episodic Care Manager - Behavioral Health Autism Services is responsible for performing clinical 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 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. Receive assigned cases 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. 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. 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.