Nurse (RN) Case Management Lead Analyst - Evernorth Health Services - Remote (Open) - The Cigna Group
Bloomfield, CT
About the Job
Required Work Hours: Must be flexible to work an 8-hour shift between the business operating hours of 9 a.m. - 9 p.m. EST. The role may require evening shifts
Major Job Responsibilities and Required Results for CM:
Obtains informed verbal consent and takes all steps to obtain written consent.
Acts with speed and purpose to identify, support and resolve customer healthcare needs.
Establishes a collaborative relationship with the Customer, client (plan participant), family, physician(s), and other providers to determine medical history and current status to assess the appropriate level of care and options for alternative care.
Sets a plan for short-term and long-term goals, time frames for follow-up, resources available (internal and community), involves all appropriate parties (client, physician, providers, employers, etc), and identifies anticipated case results/outcomes and criteria for case closure.
Promotes quality cost-effective outcomes managing care needs through the continuum of care utilizing effective verbal and written communication skills and consumerism approach through education and health advocacy to our customers
Implements, coordinates, monitors and evaluates the case management plan as appropriate.
Documents findings in a clear, concise, and accurate manner.
Acts as liaison between account, client/family, physician(s) and facilities/agencies.
Builds solid working relationships with internal team members and across Picerno organization.
Maintains accurate record (system) of case management interventions including cost/benefit analysis, savings, and data collection.
Adheres to quality assurance standards and all case management policy and procedures.
Demonstrates sensitivity to culturally diverse situations, clients and customers. Any other assigned tasks as deemed necessary to meet business needs.
Ensures the member’s privacy, confidentiality, and safety are maintained, adheres to ethical and accreditation standards, serves as a member advocate, and adheres to legal and regulatory standards.
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
Complies with all accreditation, State and Federal mandates.
Completes training as required per role and demonstrates evidence of continuing education to maintain clinical expertise and certification as appropriate
Participates in unit and corporate training initiatives and demonstrates evidence of continuing education to maintain clinical expertise and certification as appropriate.
Additional Roles and Responsibilities Specific to CM Role:
Will manage a large volume of outbound calls, are required to be available during all scheduled times, and manage calls and after call work in a timely manner.
Must like fast paced work, be able to thinking critically and demonstrate system proficiency.
Must be a high performing CM with engagement rates at or above goal.
Will be responsible for identifying and addressing any immediate customer concerns, researching and providing solutions when possible along with assessing customer for ongoing complex case management needs and assigning to a client based CM for further management when appropriate.
Must be skilled in utilization of Cigna resources when identifying need for further customer support.
Be organized, knowledgeable and thorough while promoting quality case effective outcomes, and provides quality, cost effective alternatives to acute care.
Self-motivated and able to work autonomously
Consistent Use of “Grocery List” established and used on ongoing cases
Must meet/ exceed all PMD metrics. tNPS >70%- as applicable to the aligned CM
Quality scores of >90% overall, Clinical Acumen =>80%
Clean SWAT Reports
Applies savings to cases in real time.
Comply with URAC touch rate of every 30 days.
Consistently addresses & completes CMA feedback.
Have a history of effective case load management.
Minimum Requirements:
Active Unrestricted Registered Nurse (RN) license in state or territory of the United States.
Minimum of two years full-time direct patient care experience as an RN required.
Must be bilingual in Dari or Pashto and able to fluently and proficiently communicate verbally and in writing.
Excellent time management, organizational, research, analytical, negotiation, communication (verbal and written) and interpersonal skills.
Must be proficient working with multiple computer systems independently, including Windows-based applications
Must have good clinical acumen with experience working with a variety of patients with acute and complex medical conditions
If an internal Cigna employee, CMs requires experienced, as a high-performing CM
Must have a quiet and confidential office space in your home without distractions during your shift
Must have access to high speed broadband internet in your home
Preferred requirements:
PDN experience
Case Management certification
+ Bilingual in Dari or Pashto language
Experience in TruCare and ICMS systems
Within four (4) years of hire as a case manager will possess a URAC-recognized certification in case management.
Excellent communication skills including telephonic (verbal) and digital (messaging, emails).
Skilled in clinical acumen to form a judgement and act.
Strong computer skills in Microsoft word, Excel, Outlook, and ability to perform thorough internet research.
Ability to recognize, address and resolve conflicts in a professional, collaborative manner.
Demonstrates sensitivity to culturally diverse situations, participants, and customers.
Demonstrates effective organizational skills and flexibility to meet the business needs.
Adapts approach and demeanor in real time to match the shifting demands of different situations.
Ability to manage multiple, complex situations in a fast-paced environment collaborating with clinical and other business partners.
Some roles may require on-site meetings or audits twice a year required
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.
For this position, we anticipate offering an hourly rate of 40 - 66 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.
We want you to be healthy, balanced, and feel secure. That’s why you’ll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you’ll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at Cigna Group .
About Evernorth Health Services
Evernorth Health Services, a division of The Cigna Group, creates pharmacy, care and benefit solutions to improve health and increase vitality. We relentlessly innovate to make the prediction, prevention and treatment of illness and disease more accessible to millions of people. Join us in driving growth and improving lives.
_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._
_The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State._
_Qualified applicants with criminal histories will be considered for employment in a manner_ _consistent with all federal, state and local ordinances._
Major Job Responsibilities and Required Results for CM:
Obtains informed verbal consent and takes all steps to obtain written consent.
Acts with speed and purpose to identify, support and resolve customer healthcare needs.
Establishes a collaborative relationship with the Customer, client (plan participant), family, physician(s), and other providers to determine medical history and current status to assess the appropriate level of care and options for alternative care.
Sets a plan for short-term and long-term goals, time frames for follow-up, resources available (internal and community), involves all appropriate parties (client, physician, providers, employers, etc), and identifies anticipated case results/outcomes and criteria for case closure.
Promotes quality cost-effective outcomes managing care needs through the continuum of care utilizing effective verbal and written communication skills and consumerism approach through education and health advocacy to our customers
Implements, coordinates, monitors and evaluates the case management plan as appropriate.
Documents findings in a clear, concise, and accurate manner.
Acts as liaison between account, client/family, physician(s) and facilities/agencies.
Builds solid working relationships with internal team members and across Picerno organization.
Maintains accurate record (system) of case management interventions including cost/benefit analysis, savings, and data collection.
Adheres to quality assurance standards and all case management policy and procedures.
Demonstrates sensitivity to culturally diverse situations, clients and customers. Any other assigned tasks as deemed necessary to meet business needs.
Ensures the member’s privacy, confidentiality, and safety are maintained, adheres to ethical and accreditation standards, serves as a member advocate, and adheres to legal and regulatory standards.
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
Complies with all accreditation, State and Federal mandates.
Completes training as required per role and demonstrates evidence of continuing education to maintain clinical expertise and certification as appropriate
Participates in unit and corporate training initiatives and demonstrates evidence of continuing education to maintain clinical expertise and certification as appropriate.
Additional Roles and Responsibilities Specific to CM Role:
Will manage a large volume of outbound calls, are required to be available during all scheduled times, and manage calls and after call work in a timely manner.
Must like fast paced work, be able to thinking critically and demonstrate system proficiency.
Must be a high performing CM with engagement rates at or above goal.
Will be responsible for identifying and addressing any immediate customer concerns, researching and providing solutions when possible along with assessing customer for ongoing complex case management needs and assigning to a client based CM for further management when appropriate.
Must be skilled in utilization of Cigna resources when identifying need for further customer support.
Be organized, knowledgeable and thorough while promoting quality case effective outcomes, and provides quality, cost effective alternatives to acute care.
Self-motivated and able to work autonomously
Consistent Use of “Grocery List” established and used on ongoing cases
Must meet/ exceed all PMD metrics. tNPS >70%- as applicable to the aligned CM
Quality scores of >90% overall, Clinical Acumen =>80%
Clean SWAT Reports
Applies savings to cases in real time.
Comply with URAC touch rate of every 30 days.
Consistently addresses & completes CMA feedback.
Have a history of effective case load management.
Minimum Requirements:
Active Unrestricted Registered Nurse (RN) license in state or territory of the United States.
Minimum of two years full-time direct patient care experience as an RN required.
Must be bilingual in Dari or Pashto and able to fluently and proficiently communicate verbally and in writing.
Excellent time management, organizational, research, analytical, negotiation, communication (verbal and written) and interpersonal skills.
Must be proficient working with multiple computer systems independently, including Windows-based applications
Must have good clinical acumen with experience working with a variety of patients with acute and complex medical conditions
If an internal Cigna employee, CMs requires experienced, as a high-performing CM
Must have a quiet and confidential office space in your home without distractions during your shift
Must have access to high speed broadband internet in your home
Preferred requirements:
PDN experience
Case Management certification
+ Bilingual in Dari or Pashto language
Experience in TruCare and ICMS systems
Within four (4) years of hire as a case manager will possess a URAC-recognized certification in case management.
Excellent communication skills including telephonic (verbal) and digital (messaging, emails).
Skilled in clinical acumen to form a judgement and act.
Strong computer skills in Microsoft word, Excel, Outlook, and ability to perform thorough internet research.
Ability to recognize, address and resolve conflicts in a professional, collaborative manner.
Demonstrates sensitivity to culturally diverse situations, participants, and customers.
Demonstrates effective organizational skills and flexibility to meet the business needs.
Adapts approach and demeanor in real time to match the shifting demands of different situations.
Ability to manage multiple, complex situations in a fast-paced environment collaborating with clinical and other business partners.
Some roles may require on-site meetings or audits twice a year required
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.
For this position, we anticipate offering an hourly rate of 40 - 66 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.
We want you to be healthy, balanced, and feel secure. That’s why you’ll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you’ll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at Cigna Group .
About Evernorth Health Services
Evernorth Health Services, a division of The Cigna Group, creates pharmacy, care and benefit solutions to improve health and increase vitality. We relentlessly innovate to make the prediction, prevention and treatment of illness and disease more accessible to millions of people. Join us in driving growth and improving lives.
_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._
_The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State._
_Qualified applicants with criminal histories will be considered for employment in a manner_ _consistent with all federal, state and local ordinances._
Source : The Cigna Group
