RN Utilization Management Clinical Reviewer Senior Analyst - Work from Home, Anywhere, USA

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.

Provides advanced professional input to complex Nurse Case Management assignments/projects. Plans, implements, and evaluates appropriate health care services in conjunction with the physician treatment plan. Handles more complex, high acuity cases, and/or account sensitive cases involving largest reserves. Utilizes clinical skills to assess, plan, implement, coordinate, monitor and evaluate options and services in order to facilitate appropriate healthcare outcomes for members. Ensures that case management program objectives are met by evaluating the effectiveness of alternative care services and that cost effective, quality care is maintained. Performs prospective, concurrent, and retrospective reviews for inpatient acute care, rehabilitation, referrals, and select outpatient services. May review initial liability disability claims to determine extent and impact of insured's medical condition, medical restrictions and limitations and expected duration. Performs leadership role on team when implementing new tools or case management programs/initiatives. Manages own caseload and coordinates all assigned cases. Supports and provides direction to more junior professionals. Works autonomously, only requiring “expert” level technical support from others. Exercises judgment in the evaluation, selection, and adaptation of both standard and complex techniques and procedures. Utilizes in-depth professional knowledge and acumen to develop models and procedures, and monitor trends, within Nurse Case Management. RN and current unrestricted nursing license required.

Position Scope: Manages/Coordinates an active caseload of inpatient case management cases for Cigna. Uses clinical knowledge to assess inpatient admission level of care, treatment plan and goals, identified gasps or risk for readmission or complications and any barriers to discharge. Establishes patient centric goals and interventions to meet the member’s needs while inpatient and post inpatient stay. Interfaces with facility, member, family, and other healthcare team members as well as internal matrix partners. Balances business needs with patient advocacy. Builds solid working relationships with internal staff, matrix partners, key functional areas, customers, and providers. Summary description of position: Plans, implements and evaluates appropriate health care services in conjunction with the physician treatment plan. Handles more complex, high acuity cases and /or account sensitive cases. Performs prospective, concurrent and retrospective reviews for inpatient acute care, rehabilitation, referrals and select outpatient services including DME (durable medical equipment). Ensures that inpatient case management program objectives are met by evaluating the effectiveness of alternative care services and that cost effective, quality care is maintained. Excellent time management, organization and negotiation skills. Strong research and analytical skills. Ability to assess complex issues, recommend changes and resolve problems. Knowledge of managed care preferred. Works independently, receiving direction from manager or team leader for new or unprecedented situations. Manages own caseload and coordinates all assigned cases. Acts as a resource to others. Utilizes Cigna's approved guidelines and tools to rigorously assess the clinical status of the member, the level of care and the services the member is receiving as clinically appropriate covered services. Anticipates care needs along the continuum of inpatient and outpatient services and facilitates coordination across the network of providers, participants and caregivers to assure timely discharge/transfer to an alternate level of care. Consults with manager and medical director to resolve any issues related to delay of services or barriers to discharge in a timely manner. Major responsibilities and desired results: Develops and defines a structured working relationship with key partners in inpatient facilities to support regular, effective communication and exchange of information in order to manage the member’s needs in compliance with all Federal/State/Facility contract and internal Cigna requirements. Retrieves active daily census each morning and prioritizes cases for impact. Access the approved Cigna guidelines for inpatient review and directs communication with the facility to elicit clinical information and facilitate discharge planning. Identified all cases appropriate for inpatient case management interventions, initiates and discusses options for discharge planning with the facility, provider, vendor, member and/or family and documents interactions and outcomes related to those actions. Identify and build effective relationships with a network of community, government, and knowledge resources. Maintain information on those resources and share with peers as appropriate. Act as liaison and patient advocate between account, participant, family, physician(s) and facilities/agencies. Take appropriate action to ensure participant and practitioner satisfaction within benefit constraints. Develop a participant centered plan for short term and long term objectives, including time frames for follow up. Utilize available internal and community resources in development of plan. Involve all appropriate parties (member, physician, providers, employers, etc) to determine case results/outcomes. Provide information and resources as appropriate to empower participants to take an active role in care, treatment and cost decisions. Implement, coordinate, monitor and evaluate the plan on a systematic, ongoing, appropriate basis. Negotiate price and quality care levels, intensity and durations of services. Document findings and continue to anticipate needs, determine benefit coverage status and communicate proactively to participant and members of treatment team. Identifies new referrals for complex and specialty CM programs and coordinates transition to appropriate CM when necessary. Identifies and elevates potential quality of care issues to Cigna's Quality representatives for follow up determination. Works to identify gaps in care and resolution of those identified and prevention of future gaps in care. May be required to participate in customer and auditor visits. Participates in special projects as deemed necessary. Other duties as required and related to this role.