Responsible for collaborating with healthcare providers, members, and business partners, to optimize member benefits, evaluate medical necessity and promote effective use of resources. Medical necessity reviews may include: planned elective services, surgical and diagnostic procedures, durable medical equipment and out of network services. Conduct reviews in compliance with medical policy, member eligibility, benefits, and contracts.
Essential Duties and Responsibilities:
Responsible for the effective and sufficient support of all Utilization Management activities to include review of inpatient and outpatient medical services for medical necessity and appropriateness of setting according to established policies and compliance guidelines.
Uses an established set of criteria to evaluates and authorize the medical necessity of services.
Provide notification of decisions in accordance with compliance guidelines.
Coordinate with Medical Directors when services do not meet criteria or require additional review.
Participation in staff meetings, regular trainings and other collaborative meetings as appropriate.
Works with management team to achieve operational objectives and financial goals.
Supports teams across UM Department as needed.
Active participation and completion of all required trainings.
Maintain Required Licensures.
Adherence to regulatory and departmental timeframes for review of requests
Meet/exceed department Turn Around time, daily established productivity goals, and service levels
Proficient knowledge of policies and procedures, 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
Other duties as required
Current Licensed Practical Nurse LPN or Licensed Vocational Nurse LVN.
Minimum 2-3 years clinical experience.
Experience in regulated managed care setting preferred
Strong Customer orientation
Strong organizational, planning, and communication skills
Working knowledge of insurance industry, medical coding (CPT/HCPCS/ICD-10), and overall claims process a plus
Knowledge of National Coverage Determinations, Local Coverage Determinations and MCG criteria are a plus.
Excellent time management skills
Knowledge, Skills, Abilities Required:
Excellent interpersonal and communications skills with nursing staff, physicians, nurse practitioners and other health workers involved in the care of a member
Ability to meet deadlines and manage multiple priorities, and effectively adapt and respond to complex, fast-paced, rapidly growing, and results-oriented environments
Able to work in a dynamic, fast-paced team environment and to promote team concepts
Excellent typing skills.
Substantial knowledge of Microsoft Office including SharePoint, Outlook, PowerPoint, Excel and Word.
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 hourly rate of 23 – 34 USD / hourly, 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: [email protected] for support. Do not email [email protected] 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.