Job Responsibilities:

Support the pre-authorization process and claims by assessing proposed treatment and therapies for medical necessity, appropriateness and cost-effectiveness in accordance with relevant guidelines.

Able to source and articulate said relevant guidelines while managing local to global level cases

Use clinical knowledge to assess diagnosis and treatment plans and goals, and identifies gaps in care or risks for readmission or complications.

Establish patient centric goals and interventions to meet the member’s needs.

Coordinate care and interface with the member, family members/caregivers, and the healthcare team, as well as internal matrix partners.

Establish a documented patient centric case management plan involving all appropriate parties (client, physician, providers, employers, etc), identifies anticipated case results/outcomes, criteria for case closure, and promotes communication within all parties involved.

Work with Cigna physicians and senior Case Managers to evaluate cases and receive appropriate clinical expertise on diagnosis and treatment plans.

Deliver to customers clinical programs including case management, chronic condition management, lifestyle coaching, pre assignment assessment and any other program delivered by global clinical operations.

Maintain accurate workflow and process documents.

Adhere to professional practice within scope of licensure and certification quality assurance standards and all case management policy and procedures.

Participate in unit and corporate training initiatives and demonstrates evidence of continuing education to maintain clinical expertise and certification as appropriate.

Participate in clinical projects to enhance our customer’s health and wellbeing.

Play an active role towards Cigna´s digital transformation.

Serve as clinical liaison to Clients.

Balance business needs with patient advocacy.

Experience/Knowledge, Education and Other Requirements:

Bachelor's in nursing

Clinical knowledge to assess diagnosis and treatment plans and goals, and identifies gaps in care or risks for readmission or complications

Necessary licenses and certifications for quality assurance standards and all case management policy and procedures

Strong organizational and leadership skills

Strong interpersonal and communication skills

Demonstrates problem-solving and analytical skills.

Ability to build excellent working relationships with staff, matrix partners, customers and providers

Ability to act as an “advocate” for the customer while complying with internal Policies and procedures and contractual/legal compliance requirements

Strong time management and prioritization skills

Enthusiastic with a positive attitude

Ability to operate computer, proficient with Microsoft office products, call center software, and a variety of software.

About The Cigna Group

Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. Join us in driving growth and improving lives.