Medical Review Nurse / Case Manager

About the Role We are actively recruiting for a Medical Review Nurse / Case Manager to join our Medical Review Team—night 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 and refers cases to the Medical Director per prescribed protocols. Maintains a reporting system for case activities and documents information into the clinical management system. Develops and maintains knowledge of international care management standards and documents review procedures. Educates members about country‑specific health care systems, provider capabilities, 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 for a successful transition of care. Maintains strong working relationships with internal and external customers and professionally communicates information as needed. Facilitates requests for emergency medical transport via telephonic assessment with international medical staff on site. Assists with new hire training and support, including cross‑departmental training. Assists with committee or project work as assigned. Other duties as assigned. Specific to Case Management: Collaborates with members and their caregivers/providers in assessing 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 achieve quality and cost‑effective outcomes. Requirements Current active unrestricted RN license (or pharmacist/PA license or equivalent in a Compact state). Minimum 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. Ability to manage own caseload and coordinate all assigned cases. Excellent interpersonal, negotiation, time‑management, and organizational skills. Basic computer skills. Availability for on‑call weekend and holiday rotation. Multilingual capability preferred. High energy level and excellent written and oral communication skills. Must be able to work weekends and take on‑call shifts at night and weekends on a rotational basis. Specific to Case Management: Current active unrestricted Certification in Case Management (CCM) preferred. Minimum internet speed of 75 Mbps (standard high‑speed internet access). What You’ll Get in Return Competitive base pay plus annual bonus. Competitive medical plans. Telemedicine available. Paid parental leave. Employee assistance and wellness support 24/7. Free international healthcare coverage. Other Great Perks Hybrid work model. Work abroad arrangements available. Generous PTO accrual program with carry‑over option. Nine paid holidays plus one floating holiday and one volunteer day. Tuition reimbursement. Career and learning and development opportunities. 401(k) with generous company match. Pet insurance offerings. Identity theft and legal coverages available. Emphasis on well‑being (virtual well‑being platform, monthly mindfulness events, and giveaways). #J-18808-Ljbffr BCBS Global Solutions