3 days old

Bilingual Behavioral Health Utilization Review Nurse (RN)

Memphis, TN 38103
  • Job Code
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Job Summary : The RN is an integral member of the Behavioral Health team who functions autonomously utilizing nursing psychiatric knowledge, judgment, and skills to assess and evaluate the care of patients. The RN will conduct review of requests for outpatient and inpatient Behavioral Health services, request additional clinical information as necessary, review applicable coverage guidelines, approve services that meet established criteria and/or forward requests to Medical Director for secondary review.

Essential Duties and Responsibilities:

  • This position reviews pre-certification requests for coverage and medical necessity for Behavioral Health services that require prior authorization as per Leon Medical Centers Health Plans (LMCHP), Medicare, and Medicaid guidelines and timeframes for outpatient and inpatient services.
  • Refer requests that require additional review to the Behavioral Health Medical Director.
  • Use judgment to select the appropriate guidelines/criteria to conduct reviews for inpatient and outpatient services. Utilize MCG criteria to conduct assessment of medical necessity.
  • Contact requesting providers to obtain additional information when necessary to establish medical necessity.
  • Might conduct on-site concurrent reviews at Behavioral Health acute care facilities to establish medical necessity of services being rendered.
  • Maintain open channels of communication with providers, attending physicians, and matrix partners.
  • Answer telephonic inquiries from Medical Directors and providers regarding the status of organization determinations.
  • Comply with LMCHP, Medicare, Medicaid, and state policies and procedures and maintain confidentiality of member information in accordance with state and federal laws.
  • Participate in mandatory trainings and competency testing as required.
  • Maintain up to date Behavioral Health clinical knowledge.
  • Provide appropriate referrals to Care Management department.
  • Support the Care Management team by maintaining a caseload of BH members
  • Perform other related duties assigned.


  • Registered Nurse within US is required. Must have a compact licensure or a FL RN licensure
  • Two or more years of patient-care experience in a Behavioral Health setting
  • Inpatient and outpatient experience is desired
  • Case Management is highly preferred for this role
  • Bilingual in English/Spanish is required
  • Requires that you have access to high- speed broadband wired internet with a modem. Cannot support a hot spot or satellite-based internet


  • One or more years of experience in utilization review
  • Extensive knowledge of Medicare and Medicaid guidelines
  • Bachelor's in Nursing

This position is not eligible to be performed in Colorado.

About Cigna

Cigna Corporation exists to improve lives. We are a global health service company dedicated to improving the health, well-being and peace of mind of those we serve. Together, with colleagues around the world, we aspire to transform health services, making them more affordable and accessible to millions. Through our unmatched expertise, bold action, fresh ideas and an unwavering commitment to patient-centered care, we are a force of health services innovation. When you work with us, or one of our subsidiaries, you'll enjoy meaningful career experiences that enrich people's lives. What difference will you make?

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.

Posted: 2021-06-09 Expires: 2021-07-08
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Bilingual Behavioral Health Utilization Review Nurse (RN)

Memphis, TN 38103

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