Medical Review Nurse / Case Manager

Worldwide Insurance Services • King of Prussia, PA

1h • Hybrid

About The Position

At Blue Cross Blue Shield Global SolutionsSM (BCBS Global SolutionsSM), we make it easy for people and organizations to access and pay for healthcare abroad. By combining digital innovation with human-centered care, we go above and beyond for our customers and deliver an international healthcare experience that’s simple, efficient, and human. Whether our customers live, work, travel or study abroad, we give them the confidence and peace of mind to embrace every journey and say “yes” to new possibilities. We are actively recruiting for Medical Review Nurse / Case Manager to join our Medical Review Team - night shift. The primary responsibility of the Nurse/Case Manager is to manage the Medical Review process in conjunction with Supervisors – Medical Review Team and Medical Directors. The role is a combination of Pre-authorization, Utilization Management, and Case Management.

Requirements

• A current, active, unrestricted RN license, specifically a PA license or via multistate in Compact state, or acceptable jurisdiction, with three years of clinical experience.
• Ability to independently research medical standard of care protocols across multiple resources.
• Knowledge of US managed care and experience managing care outside of the US preferred.
• Manages own caseload and coordinates all assigned cases.
• Excellent interpersonal skills and the ability to work in a team environment.
• Effective negotiation skills.
• Strong time management and organization skills.
• Basic computer skills.
• Ability to work on-call weekend and holiday rotation.
• Multilingual capability preferred.
• A high energy level and excellent written and oral communication skills are essential.
• Must be available to work weekends and take on-call shifts at night and weekends on a rotational basis.
• A current, active, unrestricted Certification in Case Management (CCM) is preferred, but not required)
• Employee is required to have at minimum an internet speed of 75 Mbps (standard high-speed internet access).

Nice To Haves

• Knowledge of US managed care and experience managing care outside of the US
• A current, active, unrestricted Certification in Case Management (CCM)

Responsibilities

• Performs prospective, concurrent, and retrospective reviews for inpatient acute care, rehabilitation, referrals, and select outpatient services following international standards of care and proprietary clinical guidelines for inpatient and outpatient covered services.
• Determines medical necessity of services provided to plan members; refers cases to the Medical Director per prescribed protocols.
• Maintains reporting system for case activities and documents information into the clinical management system as needed.
• Develops and maintains knowledge of international care management standards and documents review procedures.
• Educates members relative to country specific health care systems and health care provider capabilities and limitations; and available company health resources.
• Performs research on relevant topics in health promotion and chronic condition management, as required for specific members.
• Participates in the discharge planning process and identifies appropriate resources, both internal and external, required for a successful transition of care to an alternative setting as needed.
• Maintains strong working relationship with internal and external customers and professionally communicates information as needed or required. Participates in handover with non-clinical staff to maximize communication and case progression.
• Facilitates requests for emergency medical transport, via telephonic assessment, with international medical staff on site.
• Assist with new hire training/support including cross-departmental training and chair-siding.
• Assist with committee/project work as assigned.
• Other duties as assigned.
• Collaborates with members and their caregivers/providers in assessing their needs and coordinating and evaluating a plan of care to maximize health and achieve wellness and autonomy.
• Promotes options and services to meet the member’s needs and promote quality and cost-effective outcomes.

Benefits

• Competitive base pay + annual bonus
• Competitive medical plans
• Telemedicine available
• Paid parental leave
• Employee assistance and wellness support 24/7
• Free international healthcare coverage
• Hybrid work model
• Work abroad arrangements available
• Generous PTO accrual program with carryover option
• 9 paid holidays in addition to one floating holiday and one volunteer day
• Tuition reimbursement
• Career/Learning and development opportunities
• 401(k) with generous company match
• Pet insurance offerings
• Identify theft and legal coverages available
• Emphasis on well-being (Virtual well-being platform, monthly mindfulness events, and giveaways)

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level