The Cigna Group
Evernorth Health Services, a division of The Cigna Group, creates pharmacy, care and benefit solutions to improve health and increase vitality. We relentlessly innovate to make the prediction, prevention and treatment of illness and disease more accessible to millions of people. Join us in driving growth and improving lives.
The Nurse Clinician – RN is responsible for reviewing escalated clinical criteria reviews for providers, members and patient client advocates within the Prior Authorization/Utilization Management department. Identify and track trends for analytics reporting to ensure clinical criteria program integrity. Maintain a professional and ethical behavior at all times as outlined by the Nurse Practice Act and applicable company policies. Ideal candidate must be available to work CST, MST or PST time zones.
Active, unencumbered Registered Nurse (RN) license in state of residency. High School Diploma or GED, plus 8+ years of relevant RN experience; or 5+ years of relevant RN experience with an ASN degree; or 2+ years of relevant RN experience with a BSN degree Case management experience preferred 5+ years of experience is preferred in prior authorization or utilization review and appeals Demonstrated proficiency with Microsoft Office software; basic database navigation Ability to multitask in both PC/Phone related tasks Ability to build strong working relationships with colleagues and customers Strong time management skills and the ability to prioritize work and meet deadlines Excellent verbal and written communication skills Ability to work Monday-Friday, 8am-5pm, Eastern time Adequate home internet access will be required in this role TECHNICAL SKILLS: Experience with Cover My Meds Tool Experience with Myndshft Tool 5+ years of experience is preferred in prior authorization or utilization review and appeals Case Management experience a plus Demonstrated proficiency with Microsoft Office software; basic database navigation Ability to multitask in both PC/Phone related tasks SOFT SKILLS: Ability to build strong working relationships with colleagues and customers Strong time management skills and the ability to prioritize work and meet deadlines Excellent verbal and written communication skills Ability to work Monday-Friday, 8am-5pm, Eastern time Adequate home internet access will be required in this role COMPETENCIES: Communicates Effectively Collaborates Customer Focus Decision Quality Nimble Learning If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.
Conduct criteria reviews for commercial payers, Medicare, and Medicaid Provide prior authorization assistance, and denial appeal assistance Prepare and write medical necessity appeal letters for claim denials for commercial and government payers. Support all aspects of Patient Access and Revenue Cycle Management (PARCM), including clearance and reimbursement for multiple Therapeutic Resource Centers.
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