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

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.


* Ide...