[Hiring] Utilization Management Clinical Reviewer @The Cigna Group

Role Description

The job profile for this position is UM Clinical Reviewer Senior Analyst, which is a Band 3 Senior Contributor Career Track Role.

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Utilization Management Clinical Reviewer (California) - Remote

• Must currently reside and be a licensed RN in California
• Hours: Monday-Friday. Must be able to work an 8-hour shift between 8:00 a.m.-5:00 p.m. PST.

In this role, you will:

• Manage an active caseload, assess clinical needs and levels of care, identify barriers to discharge, and coordinate safe transitions across the care continuum.
• Collaborate with members, families, providers, facilities, and internal partners while balancing quality, affordability, benefit coverage, and member advocacy.

Responsibilities

• Manage and coordinate an assigned caseload of complex, high-acuity, or account-sensitive inpatient cases.
• Complete prospective, concurrent, and retrospective clinical reviews for acute inpatient care, rehabilitation, referrals, select outpatient services, and durable medical equipment, as applicable.
• Apply approved clinical guidelines and tools to evaluate medical necessity, level of care, covered services, treatment goals, risk factors, and discharge needs.
• Review the daily census, prioritize cases, request relevant clinical information, and document decisions, interventions, and outcomes accurately and on time.
• Create member-centered short- and long-term care plans with measurable goals, follow-up timeframes, and clear criteria for transition or closure.
• Coordinate with members, families, physicians, facilities, vendors, caregivers, and internal partners to support timely discharge or transfer to the appropriate level of care.
• Identify and help resolve gaps in care, barriers to discharge, risk for readmission, and delays in services.
• Educate members about available benefits, care options, costs, and community resources so they can take an active role in health care decisions.
• Serve as a member advocate and liaison while working within benefit, regulatory, contractual, and program requirements.
• Escalate complex cases, quality-of-care concerns, and service delays to the appropriate manager, medical director, or Quality partner.
• Identify referrals for complex or specialty case management programs and coordinate a smooth transition when needed.
• Build effective relationships with internal teams, providers, customers, and community resources.
• Support customer or auditor visits, special projects, peer consultation, and other related duties as assigned.

Qualifications

• Active, unencumbered California RN licensure
• A minimum of two years of direct clinical RN experience in an inpatient or managed care setting

Preferred Qualifications

• Bachelor’s degree in nursing or a related field.
• Ability to assess complex clinical information, identify barriers, recommend solutions, and make sound decisions.
• Strong written and verbal communication, organization, time management, research, analytical, negotiation, and problem-solving skills.
• Ability to work independently, manage competing priorities, and collaborate in a fast-paced, matrixed environment.
• Proficiency using computers and clinical or case management systems.
• Experience in medical management, utilization management, or case management within a health plan or hospital setting.
• Knowledge of managed care products, care management strategies, and community, state, and federal resources.
• Demonstrated ability to anticipate needs, coordinate services, and build cooperative relationships with diverse internal and external partners.

Compensation and Benefits

• Hourly rate of 31 - 52 USD / hourly, depending on relevant factors, including experience and geographic location.
• Eligible to participate in an annual bonus plan.
• Comprehensive range of benefits, including medical, vision, dental, and well-being and behavioral health programs.
• 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.