[Hiring] Telephonic Registered Nurse Clinical Reviewer @The Cigna Group

Role Description

The Clinical Reviewer will be responsible for:

• All clinical certification activities, which include but are not limited to evaluating telephone, fax or WEB requests for authorization of clinical services from physician offices and/or imaging centers.
• Comparing requests against established clinical protocols and authorizing services or referring requests for expert clinical review as appropriate.
• Understanding complex case specialties and case reviews.
• Reviewing clinical information submitted by providers to appropriate criteria and standards and making decisions to issue a review determination or to refer to physician review if criteria are not met.
• Maintaining current departmental standards related to productivity.
• Training in clinical certification, utilization management, URAC and NCQA principles, policies, and procedures.
• Preparing program correspondence as needed.
• Serving as a resource for members calling for assistance.
• Making outbound calls as required.
• Referring provider and member complaints, and appeals to appropriate departments.
• Maintaining patient confidentiality in accordance with EviCore standards established in compliance with HIPAA and State regulations.
• Providing outstanding customer service ensuring callers receive the highest possible service.
• Running and analyzing reports to ensure all tasks are completed in a timely fashion and meet regulatory requirements.
• Assisting team members in departmental chats, by phone and in person.
• Acting as training assistant when assigned.
• Assisting team members with questions and participating in team meetings.
• Performing related duties as required.

Essential Functions:

• Must be able to sit through shift, demonstrate advanced proficiency in MS Office applications.
• Excellent communication skills both verbal and written.
• Excellent problem solving and customer service skills are required.
• Must be self-directed and highly motivated with an ability to multi-task.
• Excellent computer skills.
• Must be able to hear and speak on the phone for an entire shift.

Qualifications

• Associates Degree in Nursing required.
• Current, unrestricted license as an RN in state of primary residence.
• Must have at least 1 year of acute care, managed care, ER, ICU experience or 2 years of clinical utilization management experience.
• If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

Requirements

• For this position, we anticipate offering an hourly rate of 31 - 52 USD / hourly, depending on relevant factors, including experience and geographic location.
• This role is also anticipated to be eligible to participate in an annual bonus plan.

Benefits

• Comprehensive range of benefits, with a focus on supporting your whole health.
• Health-related benefits including medical, vision, dental, and well-being and behavioral health programs starting on day one of employment.
• 401(k), company paid life insurance, tuition reimbursement.
• A minimum of 18 days of paid time off per year, paid holidays, and leaves of absence.