RN Utilization Management Clinical Review Analyst - Work from Home, Anywhere, USA ID-5452

Position Scope:

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. 

 

Minimum requirements:

  • Active unrestricted Registered Nurse (RN) license in state or territory of the United States

 

Preferred requirements:

  • Bachelors degree
  • 3 years clinical experience in inpatient or managed care setting
  • Demonstrated ability to anticipate, plan, coordinate and organize.
  • Knowledge of community, state and federal resources.
  • Possession of a valid driver’s license, proof of insurance, good driving record and reliable transportation.
  • Strong skills in teamwork, negotiation, conflict management, problem solving, and effective decision making.
  • Experience in medical management and case management in a managed care setting or hospital is highly desirable.
  • Ability to assess complex issues, recommend changes and resolve problems.
  • Strong computer knowledge and abilities.
  • Knowledge of managed care products and strategies.
  • Ability to work within changing business environment and balance business needs with patient advocacy.
  • Experience managing multiple projects in a fast paced matrix driven environment. 
  • Effective at negotiation, teamwork and cooperative relations with diverse internal and external stakeholders. 

 

 

 

 

 

 

 

 

 

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.

 

 

For this position, we anticipate offering an hourly rate of 27 - 40 USD / hourly, depending on relevant factors, including experience and geographic location.

 

 

This role is also anticipated to be eligible to participate in an annual bonus plan.

 

We want you to be healthy, balanced, and feel secure. That’s why you’ll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you’ll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at Cigna Group.

 

 

 

About Evernorth Health Services

 

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.

 

 

Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.

 

The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.

 

 

Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.

Back to blog

Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

This is what this question poses: When do you focus and start working seriously? What are the hours you work optimally? Are you a night owl? A morning bird? Remote teams can be made up of people working on different shifts and around the world, so you won't necessarily be stuck in the 9-5 schedule if it's not for you...

2. HOW DO YOU USE THE DIFFERENT COMMUNICATION TOOLS IN DIFFERENT SITUATIONS?

When you're working on a remote team, there's no way to chat in the hallway between meetings or catch up on the latest project during an office carpool. Therefore, virtual communication will be absolutely essential to get your work done...

3. WHAT IS "WORKING REMOTE" REALLY FOR YOU?

Many people want to work remotely because of the flexibility it allows. You can work anywhere and at any time of the day...

4. WHAT DO YOU NEED IN YOUR PHYSICAL WORKSPACE TO SUCCEED IN YOUR WORK?

With this question, companies are looking to see what equipment they may need to provide you with and to verify how aware you are of what remote working could mean for you physically and logistically...

5. HOW DO YOU PROCESS INFORMATION?

Several years ago, I was working in a team to plan a big event. My supervisor made us all work as a team before the big day. One of our activities has been to find out how each of us processes information...

6. HOW DO YOU MANAGE THE CALENDAR AND THE PROGRAM? WHICH APPLICATIONS / SYSTEM DO YOU USE?

Or you may receive even more specific questions, such as: What's on your calendar? Do you plan blocks of time to do certain types of work? Do you have an open calendar that everyone can see?...

7. HOW DO YOU ORGANIZE FILES, LINKS, AND TABS ON YOUR COMPUTER?

Just like your schedule, how you track files and other information is very important. After all, everything is digital!...

8. HOW TO PRIORITIZE WORK?

The day I watched Marie Forleo's film separating the important from the urgent, my life changed. Not all remote jobs start fast, but most of them are...

9. HOW DO YOU PREPARE FOR A MEETING AND PREPARE A MEETING? WHAT DO YOU SEE HAPPENING DURING THE MEETING?

Just as communication is essential when working remotely, so is organization. Because you won't have those opportunities in the elevator or a casual conversation in the lunchroom, you should take advantage of the little time you have in a video or phone conference...

10. HOW DO YOU USE TECHNOLOGY ON A DAILY BASIS, IN YOUR WORK AND FOR YOUR PLEASURE?

This is a great question because it shows your comfort level with technology, which is very important for a remote worker because you will be working with technology over time...

Related Posts