Medical Review Nurse

3 weeks ago

King of Prussia, United States Worldwide Insurance Services Full time
Job DescriptionJob Description

We are actively recruiting for Medical Review Nurse / Case Managers to join our Medical Review Team The primary responsibility of the Nurse/Case Manager is to manage the Medical Review process in conjunction with GeoBlue’s Supervisors – Medical Review Team and Medical Directors. The role is a combination of Pre-authorization, Utilization Management, and Case Management.


Please note - our current openings are on NIGHT SHIFT. We currently have two openings on the Tuesday - Saturday, 10 PM EST - 6 AM EST shift.

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 GeoBlue 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.
  • Specific to Case Management:
    • 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.

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.
  • Specific to Case Management –
    1. 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).

Working Conditions:

  • Flexibility to work in an office and/or at-home, remote office environment.
  • Schedule flexibility is occasionally necessary in this position. Individual may be required to attend key business/departmental meetings and/or perform certain business critical job functions outside of normal working hours.
  • Physical Demands: Must be able to communicate internally and externally through receiving and responding to auditory and visual methods.

Internal Pay Grade: 10

The starting pay for this role is $66,023 to $84,179 based on skill level and experience in a similar role.


This job description reflects management’s assignment of essential functions; it does not prescribe or restrict the tasks that may be assigned.

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