Under the supervision of the Health Services Management Supervisor and Manager of Inpatient Utilization Management, the Inpatient Review Nurse is responsible for effective, efficient medical management of the population. The Inpatient Review Nurse is responsible for the effective, efficient & proactive completion of all utilization management activities that facilitate the member's movement through the continuum of care. Responsibilities include prospective, concurrent & retrospective reviews of Inpatient, LTAC, SNF & Rehabilitation members in their area of assignment. Medical necessity determinations and appropriateness of setting will be determined based on established policies and approved criteria.
Performs all utilization review activities according to Health Services policy and procedures. Conducts onsite/telephonic review as assigned to obtain required information.
Evaluates and authorizes the medical necessity of inpatient and observation services as assigned by application of approved criteria and established policies and guidelines.
Notifies hospital and/or provider of recommended changes in level of care when applying approved criteria and established policies and guidelines.
Facilitates the movement of the member through the continuum of care in a proactive manner.
Refers cases to the Medical Director/POD Medical Director as appropriate.
Concurrently enters all information into the healthplan's computer documentation system ensuring complete and accurate information per established policies and guidelines.
Completes opportunity report concurrently and any other reports or request for information in a timely manner.
Notifies hospital and/or providers of all denials and generates the denial letters template to forward to the Denial team as directed by the Medical Director within assigned time frames.
Evaluates each case for quality of care, documents quality issues and appropriately refers cases to the quality management coordinator
Reviews selected retrospective requests for certification and follow-up as necessary with Health Services Supervisor, Manager of Inpatient Utilization or Medical Director.
Participates in education of providers regarding Health Services policies and procedures.
Identifies and refers cases concurrently to CM or Rapid Response unit as appropriate and indicated in established policies and guidelines.
Performs member/family interviews and assists in discharge plan development and coordination of care.
Maintains strong working relations with internal and external customers. Presents all communication in a positive and professional manor.
Acts as a liaison for the health plan with outside entities, including, but not limited to physicians, hospital, health care vendors and facility Case management Departments.
Attends and actively participates in staff meetings and is responsible for reviewing information presented.
Maintains confidentiality in all aspects of operations. Complies with Corporate, Federal, and State confidentiality standards to ensure the appropriate protection of member identifiable health information.
Facilitates referrals for follow up care with delegated entities.
Maintains strong working relationships with Health Plan Medical Directors, Inpatient Managers, POD Inpatient Medical Directors and POD administrators.
Actively participates in network meetings as scheduled and requested.
Actively participates in mandatory weekly CHT rounds
Actively participates in identification of opportunities for improvement and assists with action plan development and problem resolution.
Knowledgeable in workflow, productivity and timeliness standards for all programs services.
Completes and meets minimal IRR and audit standards.
Completes and passes yearly Interqual Training session.
Prepares report and conducts analysis of POD specific information & communication. Reviews these results with POD Inpatient Medical directors prior to Inpatient Utilization Manager Meetings.
Attends and actively participates in assigned POD Inpatient Manager Meetings as scheduled.
Available and responsive to health plan and facility partners during regularly scheduled business hours.
Supports an environment which fosters teamwork, cooperation, respect, and diversity. Establishes and maintains positive communication and professional demeanor with coworkers, delegates, vendors and members at all times. Demonstrates and supports commitment to organizational and plan goals and objectives.
Maintains all necessary educational requirements for required licensure and certifications.
Performs other related duties and projects as assigned.
Adheres to Organizational policies and procedures.
Supports and carries out the Organizational Mission & Values.
This role is patient facing & you must be fully vaccinated OR be required to undergo testing twice a week. Note, in some locations local law requires the clinician to be vaccinated with no testing option, in those locations local law takes precedent.
Cigna Corporation exists to improve lives. We are a global health service company dedicated to improving the health, well-being and peace of mind of those we serve. Together, with colleagues around the world, 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 us, or one of our subsidiaries, you'll enjoy meaningful career experiences that enrich people's lives. What difference will you make?
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.