At Cigna, we're more than a health insurance company. We're a global health service company.
Responsible for collaborating with healthcare providers and members to optimize member benefits and to promote effective use of resources. Assesses the medical necessity of inpatient admissions, outpatient services, surgical and diagnostic procedures, home health care, durable medical equipment and out of network services. Will conduct pre-certification to ensure compliance with medical policy, member eligibility, benefits, and contracts with CMS guidelines.
* Responsible for the effective and sufficient support of all Utilization Management activities to include prospective/pre-certification review of inpatient and outpatient medical services for medical necessity and appropriateness of setting according to established policies. Primary responsibilities will be Expedited Organization Determination and Member Organization Determinations.
* Uses an established set of criteria, evaluates and authorizes the medical necessity of inpatient and outpatient services.
* Notifies provider of recommended changes in level of care.
* Review requests from members and contacts member as needed for additional information
* Communicate decisions to member within CMS guidelines
* Issue letters to provider and member if the service meets certification criteria, and escalates to manager or Medical Director for review if the service does not meet certification criteria, and may issue denial letters.
* May participate or assist in the planning of team and attend meetings.
* Works with management team to achieve financial goals and operational objectives.
* Current licensure as a Licensed Practical Nurse LPN or Licensed Vocational Nurse LVN.
* At least one year clinical experience.
* Excellent communication and interpersonal skills.
* Excellent time management skills.
* Working knowledge of the insurance industry and the overall claims process a plus.
* Knowledge of UM and CM products.
* ·Proficient in basic computer skills
**Knowledge, Skills, Abilities Required:**
* Excellent interpersonal and communications skills with clinical staff, management, and all departments involved in the care of our customers.
* Ability to meet deadlines and manage multiple priorities, and effectively adapt and respond to complex, fast-paced, rapidly growing, and results-oriented environments
* Ability to make decisions on what needs to be done based on clearly established guidelines
* Able to work in a dynamic, fast-paced team environment and to promote team concepts
* Willing to work varying shifts including weekends and Holidays on a rotating or regular basis
* Ability to work independently from home, previous experience working from home preferred
* Substantial knowledge of Microsoft Office including SharePoint, Outlook, PowerPoint, Excel and Word.
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