27 days old

Case Management Analyst, Texas work from home

829 GulfQuest, LP
Bloomfield, CT 06002
  • Job Code
    20014859

POSITION SUMMARY

The UM Case Coordinator is responsible for ensuring medically necessary health care services are provided for Cigna HealthSpring members in a cost-effective manner and within the scope of their benefits.

Texas based work from home.

ESSENTIAL FUNCTIONS

  • Responsibilities include collecting, analyzing, and evaluating clinical documentation received using established criteria to determine appropriateness of clinical decisions
  • Adherence to regulatory and departmental time frames for review of requests received
  • Responsible for the effective and sufficient support of all utilization management activities to include prospective/ pre-certification review of outpatient medical services for medical necessity and appropriateness of setting according to established policies
  • Using an established set of criteria evaluates and authorizes the medical necessity of outpatient services
  • Maintaining accurate system documentation and meeting documentation requirements established by department
  • Evaluates cases for quality of care and documents quality issues
  • Issues letter to provider if the service meets certification criteria, and escalates to manager or Medical Director for review if the service does not meet certification criteria, and may issue adverse clinical determination correspondence for members, contracted and non contracted providers
  • Responsible for steering members to in-network providers when possible
  • Ability to utilize multiple computer programs and resources
  • Initiate the letter of agreement process, working with Network Operations to ensure Service Level Agreements are completed in a timely manner when applicable
  • Proficient knowledge of Health Services policies and procedures, Medicaid, Medicare, HIPPA and NCQA standards
  • Professional demeanor and the ability to work effectively within a team or independently
  • Flexible with the ability to shift priorities when required

QUALIFICATIONS

  • Currently employed with Express Scripts or Cigna as a contractor
  • High School Diploma or GED
  • Must have current license as a Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN) with no restrictions
  • Must have one year Utilization review experience, plus five years clinical experience
  • Excellent investigational, analytical, organizational and critical thinking skillsStrong computer skillsrequired
  • Excellent communication, organization and written skills
  • Ability to meet deadlines and manage multiple priorities.
  • Detail oriented with analytic perspective
  • Ability to work in a fast-paced, rapidly growing, high-volume, results oriented environment
  • Knowledge of criteria used to review for medical necessity (InterQual/Milliman)
  • Proficiency with Microsoft Office products (Outlook, PowerPoint, Excel and Word)
  • Strong typing skills and proficiency in documentation with minimal grammatical errors.

ABOUT CIGNA

First things first, were a global health service company dedicated to helping people improve their health, well-being and sense of security. But we dont just care about your well-being, we care about your career health too. Thats why when you work with us, you can count on a different kind of career youll make a difference, learn a ton, and share in changing the way people think about healthcare.

About Cigna

Cigna Corporation (NYSE: CI) is a global health service company dedicated to improving the health, well-being and peace of mind of those we serve. We offer an integrated suite of health services through Cigna, Express Scripts, and our affiliates including medical, dental, behavioral health, pharmacy, vision, supplemental benefits, and other related products. Together, with our 74,000 employees worldwide, 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 Cigna, youll enjoy meaningful career experiences that enrich peoples lives while working together to make the world a healthier place. What difference will you make? To see our culture in action, search #TeamCigna on Instagram.

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: 2020-09-04 Expires: 2020-10-03
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Case Management Analyst, Texas work from home

829 GulfQuest, LP
Bloomfield, CT 06002

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