RN Nurse Community Case Manager

At Cigna, we're more than a health insurance company. We're a global health service company.

* Identifies high-risk/high-cost patients for possible case management intervention. * Interfaces with providers of medical services and equipment to facilitate effective communication, referrals, development of discharge planning, and alternative treatment plan development. * Identifies customer needs, coordinates and support planned and unplanned transitions and post discharge follow up calls which may include primary care physician and specialist appointment scheduling * Initiates contact with patient/family, physician, and health care providers/suppliers to discuss the alternative treatment plan. Conducts on-site evaluations (customer home visits) as is necessary. * Documents all customer and provider contact, clinical notes, short term, long term and prioritize goals and revisions to the individual care plan in the integrated care management system * Collaborates with the attending physician to achieve identified patient outcomes. * Develop and implement individual care plans with customer * Communicate care plan with customer and physician * Extends, revises or closes care plan goals as is appropriate. * Refers questionable case management cases or requests to the Medical Director * Communicates in writing to the appropriate parties regarding case management decisions. * Communicates denial decisions to all appropriate parties following established guidelines, when dealing with a denied authorizations such as, but not limited to, out-of-network referrals * Evaluates each case for quality of care, documents quality issues and appropriately refers cases with questionable quality of care to the Manager of Quality Assurance. * Attend and participate in weekly Complete Health Team rounds * Perform telephonic outreach or home visits, as needed * Communicates with all departments to resolve issues or document trends. * Understands and follows administrative guidelines (policy and procedure) of the unit. * Attends and actively participates in staff meetings. * Other Duties as assigned.

* Current Licensure as a registered nurse, in the state of Texas in good standing. * Associates degree, diploma or B.S. in Nursing * Five (5) years recent experience in an acute-care environment, or * Two years (2) years recent experience in a case-management or utilization management position * Certified Case Manager preferred