Job Description

• Job Description Summary

Provides advanced professional input to complex Nurse Case Management assignments/projects. Plans, implements, and evaluation of 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 effectiveness 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 directions 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.

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POSITION SUMMARY

Provides case management support and education to patients on assigned caseload through remote contact with patients. This includes relationship building, assisting with navigating insurance and pharmacy protocols to obtain medication, referral source, and customized product and disease state training.

• Adheres to principles as stipulated by program specific contractual agreements and company practices which may include:
• Interact and build relationships with assigned patients throughout the duration of the program.
• Provide patient centric education regarding treatment and disease states for assigned products.
• Manage caseload including schedule maintenance and adherence, scheduled calls/interactions, updating program database per company protocols.
• Coordinate meetings between patients and clinical partners.
• Deliver customized interactions based on patient's needs.
• Participates in program specific customer meetings and training sessions.
• Participates in program specific orientation meetings and demonstrates clinical and systems competency on tests.
• Performs special projects and performs other duties as it pertains to specific contract performance

QUALIFICATIONS

• Associate's degree and professional nursing license (current and valid) in state of practice
• 2-5 years relevant experience of prior authorization submission experience using CoverMyMeds or other like electronic prior authorization tools.
• Min 5-10 years' experience in hospital setting or pre authorization experience, utilization review and appeals is great but not required.
• experience with prior authorization appeals or deny claims on behalf of patients.
• Registered Nurse
• Demonstrated proficiency with Microsoft Office software, basic database navigation
• Knowledge of pharmacy, pharmaceuticals, life sciences, or healthcare business required.
• Ability to multitask in both PC/Phone related tasks.
• Works effectively and fosters teamwork; Demonstrates ownership of projects and carries responsibility for building strong working relationships with colleagues and customers.
• Results oriented; demonstrated ability to prioritize and manage workload and meet project deadlines.
• Excellent communication skills both verbal and written

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 annual salary of 76,600 - 127,600 USD / yearly, 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.

If you require reasonable accommodation in completing the online application process, please email: SeeYourself@cigna.com for support. Do not email SeeYourself@cigna.com for an update on your application or to provide your resume as you will not receive a response.

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.

Job Tags

Holiday work, Permanent employment, Contract work, Local area, Remote job,

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