RN Nurse Case Manager Specialist, Work From Home, Houston, Texas

Cigna Houston , TX 77020

Posted 2 months ago

Primary Function:

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.

About Cigna

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.

icon no score

See how you match
to the job

Find your dream job anywhere
with the LiveCareer app.
Mobile App Icon
Download the
LiveCareer app and find
your dream job anywhere
App Store Icon Google Play Icon

Boost your job search productivity with our
free Chrome Extension!

lc_apply_tool GET EXTENSION

Similar Jobs

Want to see jobs matched to your resume? Upload One Now! Remove
Transplant Nurse Case Manager RN Telecommute

Unitedhealth Group Inc.

Posted 2 days ago

VIEW JOBS 10/23/2021 12:00:00 AM 2022-01-21T00:00 Combine two of the fastest-growing fields on the planet with a culture of performance, collaboration and opportunity and this is what you get. Leading edge technology in an industry that is improving the lives of millions. Here, innovation is not about another gadget; it is about making health care data available wherever and whenever people need it, safely and reliably. There is no room for error. If you are looking for a better place to use your passion and your desire to drive change, this is the place to be. It's an opportunity to do your life's best work.(sm) As a Telephonic Transplant Nurse Case Manager RN, you will drive positive outcomes by supporting a diverse member population with education, advocacy and the connections to the resources they need. This is a telecommute / work from home position. Shift is Monday - Friday from 8am - 5 pm. Shift requires some days to be worked until 6pm as needed. You'll enjoy the flexibility to telecommute* from Central, Mountain or Pacific time zones in the USA as you take on some tough challenges. Primary Responsibilities: * Making outbound calls to assess members' current health status * Identifying gaps or barriers in treatment plans * Providing patient education to assist with self-management * Interacting with Medical Directors on challenging cases * Coordinating care for members * Making referrals to outside sources * Coordinating services as needed (home health, DME, etc.) * Educating members on disease processes * Encouraging members to make healthy lifestyle changes * Documenting and tracking findings * Utilizing Milliman criteria to determine if patients are in the correct hospital setting * Making welcome home calls to ensure that discharged member receive the necessary services and resources This position will require active and unrestricted Nursing licensure in multiple US States. Selected candidate must be willing and able to obtain and maintain multiple state licensure. (Application fees and filing costs paid for by UHG) You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: * Current, unrestricted RN license in your state of residence * Multiple state licensure (in addition to Compact License if applicable) or ability to obtain multiple state nursing licenses * 2+ years of experience as an RN in a hospital setting, acute care, direct care experience or experience as a telephonic Case Manager for an insurance company * 1+ years of Transplant, ICU, Cardiology or Oncology experience working as an RN * Basic level of proficiency with Microsoft Word, with the ability to navigate a Windows environment * Access to high speed internet from home (Broadband cable, DSL or fiber) * Dedicated workspace from home * Full COVID-19 vaccination is an essential requirement of this role. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination prior to employment to ensure compliance. Preferred Qualifications: * Bachelor's Degree * Reside in compact state and have compact license * Certified Case Manager (CCM) * 3+ years of transplant experience working in an environment where transplant was the main focus of your job * Background in managed care (MCO) or insurance setting * Case Management experience * Experience working with bone marrow transplants * Experience / exposure with discharge planning * Experience in utilization review, concurrent review and/or risk management * Solid organizational skills and multitasking abilities will be keys to success UnitedHealth Group requires all new hires and employees to report their COVID-19 vaccination status. Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.(sm) Colorado Residents Only: The salary range for Colorado residents is $53,300 to $95,100. Pay is based on several factors including but not limited to education, work experience, certifications, etc. As of the date of this posting, In addition to your salary, UHG offers the following benefits for this position, subject to applicable eligibility requirements: Health, dental, and vision plans; wellness program; flexible spending accounts; paid parking or public transportation costs; 401(k) retirement plan; employee stock purchase plan; life insurance, short-term disability insurance, and long-term disability insurance; business travel accident insurance; Employee Assistance Program; PTO; and employee-paid critical illness and accident insurance. * All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment Job Keywords: Transplant Nurse Case Manager RN , Transplant Coordinator, Transplant Nurse, Bone Marrow Transplant, Solid Organ Transplant, Telecommute, Telecommuter, Telecommuting, Work From Home, Remote, Central Time Zone, CST, Mountain Time Zone, MST, Pacific Time Zone, PST Phoenix, AZ, Arizona, Denver, CO, Colorado, Houston, Dallas, TX, Texas, St Louis, MO, Missouri Unitedhealth Group Inc. Houston TX

RN Nurse Case Manager Specialist, Work From Home, Houston, Texas