Remote Nurse Case Management Lead Analyst (Clinical Appeals)

Cigna Healthcare

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Posted Date:10/17/2023

Job Id 23017150

This role will require some weekends and holidays and shift flexibility. Must be able to work shift as assigned and meet this business expectation for flexibility. This is a FT Permanent role and expectation is to work full-time .

Hours: Work shift hours will be an 8-hour shift between the parameters of 8am – 7pm. Hours are subject to change as the compliance expectations of the role evolve. Flexibility is required

This role functions as a Utilization Review RN. The position provides clinical review and decision-making following specific clinical coverage position criteria and established clinical guidelines for targeted health claims and customer and healthcare professional appeals. The nurse decision-making is based on Cigna’s accepted clinical criteria sets, regulatory requirements, contractual benefits and specific customer medical circumstances. Coverage recommendations on claims and appeals that require further professional or committee review are referred to a medical director following established policies and regulatory requirements. Conducts clinical determinations and/or recommendations on both Pre-service and Post-service Inpatient and Outpatient services for failure to prior authorize per the customer’s plan requirements using clinical criteria, the appropriate Nurse empowerment and/or physician referral policies. Conducts clinical appeal reviews for both level 1 and level 2 healthcare professionals and facilities and highly regulated customer appeals.

The Utilization Review Nurse (RN) conducting retrospective clinical claim reviews and clinical appeals reviews reports to the Health Services Senior Specialist or Case Manager Senior Specialist (licensed clinical professional manager).

Must be independent and take the ball and run with, excellent computer skills. Must be intermediate to advanced on computer and to be able to work with computers and must be able to learn difficult info. Production driven environment.

Qualifications:

·        Requires a valid RN licensure in the state of residency without any restrictions or stipulations

·        1 year of nursing experience is required. Three years of nursing experience preferred

·        Strong computer skills; good understanding of how the computer works and comfort navigating through different system applications. Should have the ability to troubleshoot computer issues.

·        Strong typing skills; knowledgeable of Microsoft Office- Word, PowerPoint, Excel; knows how to use Outlook for emails and calendar. If they have only done computerized charting or FB this is not enough. Must be able to type using two hands.

·        Works well independently. Aware of limitations and knows when to ask for assistance.

·        Strong problem solving and critical thinking skills.

·        Ability to change direction easily and ability to learn and apply quickly.

·        Must be able to work in a fast paced environment with changing priorities.

·        Ability to deal with complex issues with multiple steps/resources involved in resolution.

·        Should not be easily frustrated and should be able to cope with disappointment.

·        Should be able to work well under pressure, meet timelines and production goals.

·        Must have reliable cable, internet and power if they work from home. Time lost with any issues that do not originate within Cigna are the responsibility of the employee to make up.

·        Tenacious and Persistent

·        May be required to sit for long periods of time.

·        Must have office space where Cigna equipment can be secured and a space that is conducive to a healthy, productive work environment.

·        Hours are flexible,, but the applicant must be available to work during Cigna core business hours.  Work hours have to be approved by the manager.  Work hours are not guaranteed to be permanent and applicant must be willing to adapt should business needs change.

·        This is a dynamic environment and the applicant must be willing to grow, train in new roles and may be asked to work multiple lines of business

 

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 70,400 – 117,300 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 Cigna Healthcare

Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. 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.