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Pre-certification/Utilization Review Nurse-Onsite Philadelphia, PA! at Cigna

Posted in Management 30+ days ago.

This job brought to you by eQuest

Type: Full-Time
Location: Philadelphia, Pennsylvania

Job Description:

Position Summary: 
The Nurse is responsible for supporting the Medical Director and Director of Pre-Certification. Responsibilities include assuring health care services are available to Cigna HealthSpring members in an appropriate cost-effective manner and delivery of those services to promote healthy outcomes. 

Essential Duties and Responsibilities: 
• Responsibilities include collecting, analyzing, and evaluating clinical documentation received using established criteria to determine appropriateness of clinical decisions; Meet/exceed service level goals (e.g., Grade of Service, Average Handle Time, Average Speed to Answer, Abandonment Rate)
• Adherence to regulatory and departmental timeframes for review of requests received
• Collaborates with the Medical Director to identify utilization trends and generation of monthly written reports
• Process approval and adverse clinical determination correspondence for members related to Prospective request for services
• Initiate the letter of agreement process, working with Network Management to ensure  Service Level Agreements are completed in a timely manner when applicable
• Proficient knowledge of Health Services 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
• Coordinates with member, family, and caregivers to help resolve barriers to care 
• Successfully collaborates with member and family to assure comprehension of available resources

• HSD or GED required; BSN preferred
• Active RN license required
• 1+years’ experience in a Managed Care environment
• Intermediate knowledge of Microsoft Office including SharePoint, Outlook, PowerPoint, Excel and Word
• Working knowledge of medical coding (CPT/ICD-9) and medical necessity criteria (e.g., InterQual, Highmark, Trail Blazer)
• 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

*Monday-Friday 8:30AM-5:00PM with some overtime required
*On call requirement: 2 weeks (self assigned) during the year MIN
*2-3 holidays required per year

Position is onsite in our Philadelphia office at:
1500 Spring Garden St.