Cigna Medicare Population Health Nurse Case Management Senior Analyst

Job Description:

Delivers specific delegated tasks assigned by a supervisor in the Nurse Case Management job family.

Plans, implements, and evaluates appropriate health care services in conjunction with the physician treatment plan.

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.

Provides clinical assessments, health education, and utilization management to members.

Performs prospective, concurrent, and retrospective reviews for inpatient acute care, rehabilitation, referrals, and select outpatient services.

Manages own caseload and coordinates all assigned cases.

Completes day-to-day Nurse Case Management tasks without immediate supervision but has ready access to advice from more experienced team members.

Tasks involve a degree of forward planning and anticipation of needs/issues.

Resolves non-routine issues escalated from more junior team members.

RN and current unrestricted nursing license required.

Position Summary:

Plans, implements, and evaluates appropriate health care services to assist the customer throughout the continuum of care.

Utilizes clinical skills to assess, coordinate, monitor and evaluate options and services in order to facilitate appropriate health care outcomes for customers.

Ensures that case management program objectives are met by evaluating the effectiveness of alternative care services and that cost effective, quality care is maintained.

Maintains current knowledge of Cigna Healthcare Policies and Procedures, CMS requirements, State Medicaid requirements, NCQA standards and recommendations impacting care coordination, and Special Needs Plans Model of Care program goals and requirements, as applicable.

Essential Duties and Responsibilities:

• Outreach to customers for coordination of care and continuity of care management.

• Identify customer needs, coordinate and support planned and unplanned transitions, conduct post discharge follow up contact, which may include primary care physician and specialist appointment scheduling.

• Provide clinical assessments, health education, and utilization management to customers, as needed.

• Initiate contact with customer/caregiver/family, primary care physician, and health care providers/suppliers as needed.

Conduct health risk assessments, which may include on-site evaluations (customer home visits) as needed.

• Develop and monitor customer's individualized plan of care, as well as communicate the plan of care to the customer and primary care physician.

Prioritize case goals, monitor the completion of care goals and modify the individualized plan of care in the integrated care management system as needed.

•Document all encounters with the customer and practition...