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

• Job Description Summary

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.

Job Description

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, ini