Cigna Pittsburgh , PA 15201
This is an in office role doing Complex Case Management. The role will office out of:
Pittsburgh, PA- 2000 Park Lane Robinson office location
Major responsibilities and desired results:
Obtains informed verbal consent and takes all steps to obtain written consent as appropriate.
Establishes a collaborative relationship with client (plan participant/member), family, physician(s), and other providers to determine medical history and current status and to assess the options for optimal outcomes.
Promote consumerism through education and health advocacy.
Assesses member's health status and treatment plan and identifies any gaps or barriers to healthcare. Establishes a documented patient centric case management plan involving all appropriate parties (client, physician, providers, employers, etc), identifies anticipated case results/outcomes, criteria for case closure, and promotes communication within all parties involved.
Implements, coordinates, monitor and evaluates the case management plan on an ongoing, appropriate basis.
Negotiates price, level of care, intensity and duration with provider(s), as appropriate.
Acts as a timely and proactive liaison between account, client/family, physician(s) and facilities/agencies
Maintains accurate record (system) of case management interventions including cost/benefit analysis, savings, and data collection.
Adheres to professional practice within scope of licensure and certification quality assurance standards and all case management policy and procedures
Compliant with all accreditation, State and Federal mandates
Delivers utilization review services when member is in active case management as appropriate
Participates in unit and corporate training initiatives and demonstrates evidence of continuing education to maintain clinical expertise and certification as appropriate.
Demonstrates sensitivity to culturally diverse situations, clients and customers.
Based on experience, may provide leadership, preceptor/mentorship, support and coverage to other case management staff and assist case managers in achieving positive outcomes and savings
Engage our CAC partner (Embedded Care Coordinator) to support service to our customers.
Active RN license required
CCM certification preferred
Bachelor Degree in Nursing preferred
Strong computer skills required
A minimum of 3 years in direct clinical care required
A minimum of 3 years clinical experience required
Discharge planning / case mgt experience preferred