Position Summary:

Responsible for collaborating with healthcare providers and members to optimize member benefits and to promote effective use of resources. Assesses the medical necessity of inpatient admissions, outpatient services, surgical and diagnostic procedures, and out of network services. May also manage appeals for services denied. May conduct pre-certification, concurrent and retrospective reviews to ensure compliance with medical policy, member eligibility, benefits, and contracts. May be responsible for day-to-day operations of a single or multiple IPA/IPOD and staff, and may serve as liaison with the local health plan to ensure continuity for IPA/IPOD members.

Essential Duties and Responsibilities:

• Responsible for the effective and sufficient support of all Utilization Management activities to include prospective/pre-certification review of inpatient and outpatient medical services for medical necessity and appropriateness of setting according to established policies.


• Uses an established set of criteria, evaluates and authorizes the medical necessity of some inpatient and outpatient services.


• Notifies provider of recommended changes in level of care.


• Evaluates cases for quality of care and documents quality issues.


• Issues letter to provider and member if the service meets certification criteria, and escalates to manager or Medical Director for review if the service does not meet cerification criteria, and may issue denial letters.


• May participate or assist in the planning of team, UM/QM, PCP, IPA and or Health Plan meetings.


• Works with management team to achieve financial goals and operational objectives.

Qualifications:

Candidate must reside in Texas

• Current licensure as a Licensed Practical Nurse LPN or Licensed Vocational Nurse LVN. At least one year clinical experience.

• Excellent communication and interpersonal skills.


• Excellent time management skills.


• Working knowledge of the insurance industry and the overall claims process a plus.


• Knowledge of UM and CM products.


• Proficient in basic computer skills

Knowledge, Skills, Abilities Required:

• Excellent interpersonal and communications skills with clinical staff, management, and all departments involved in the care of our customers.


• Ability to meet deadlines and manage multiple priorities, and effectively adapt and respond to complex, fast-paced, rapidly growing, and results-oriented environments


• Ability to make decisions on what needs to be done based on clearly established guidelines


• Able to work in a dynamic, fast-paced team environment and to promote team concepts

Computer Skills:

Substantial knowledge of Microsoft Office including SharePoint, Outlook, PowerPoint, Excel and Word

This position is not eligible to be performed in Colorado.

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, you'll enjoy meaningful career experiences that enrich people's 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.