Nurse (RN) Case Management Lead Analyst - Work from home - AZ Medicare at 091 Cigna Health & Life Ins. Co. in Memphis, Tennessee

Job Description:

Summary

The Population Coordinator supports medical management for Medicare Advantage with increased emphasis on those members that are at risk for increased utilization of services.  Support is evidenced by assisting members with care transitions between settings, examining utilization criteria and using clinical expertise to help support the transition process. In addition, the Population Health Program Supervisor assists with development, implementation and monitoring of quality and outcome measures. This position also reviews data to assess for trends in populations and conditions and in order to positively impact departmental productivity and performance outcomes.

Clinical Responsibilities and Essential Functions

• Acts as a liaison and patient advocate between patient, patient families, practice clinicians, specialists, facilities/agencies by providing supporting medical information and facilitating communication though the continuum of care.


• Identifies cases appropriate for long-term case management and follows process for referral.


• Works effectively with Complex Case Manager to coordinate case transition when needed.


• Identifies and builds effective relationships with a network of community, government and knowledge resources.


• Leads an interdisciplinary team to manage the population health needs of the Medicare Advantage and other payers’ patients.


• Ensures that care teams are using appropriate readmit risk assessment tools, such as HRA’s, LACE (or similar tool), Four Domains (or similar tool). Uses risk scoring to lead appropriate prioritization of services to ensure patient safety and reduce readmission risk.


• Monitors and analyzes inpatient and outpatient data to identify admission and readmission trends, root causes for admissions.


• Through data analysis, case studies and trending reports, identifies and recommends projects that may decrease utilization.


• Is a content expert on programs, services and processes that reduce hospitalizations and re-hospitalizations and can educate and lead teams in initiatives that decrease unnecessary utilization


• Provides input related to needed changes in policies and procedures for contract and accreditation compliance.


• Contributes to changes in Population Health Management Programs routinely as needed to improve outcomes and performance


• Identifies and implements opportunities to improve outcomes, service and business processes.  Is accountable for meeting patient outcome metrics for their zone.

Complexity and Scope

• Interacts with all levels of staff in a variety of departments; physicians, patients, families and external contacts, such as employees of other healthcare institutions community providers and agencies concerning the healthcare of the patient.


• Supervises LPN clinical staff to ensure excellent patient care. Incumbents work in a fast paced, sometimes stressful environment with a strong focus on customer service.


• This position is mostly transactional in nature. 

Physical Demands/Environmental Factors

• Needs adequate hearing and visual acuity.


• Requires fine motor skills, adequate eye hand coordination, and ability to grasp and handle objects.


• Able to use proper body mechanics to assist patients in ambulating, transferring on and off of stretchers, exam tables, chair, or wheelchair.


• May be required to lift 50 pounds.


• Needs to communicate effectively through reading, writing, and speaking in person or on telephone.


• Use of computers and office equipment will be required.

Critical Behaviors

• Exceptional written and verbal communication skills that demonstrate Cigna Health Plan of Arizona’s commitment to superior customer service and quality of care and shows concern for each and every internal and external customer


• Communicates effectively well with diverse audiences that include non-licensed and highly-licensed individuals, medical directors and senior leaders within Cigna and external organizations.


• Is willing to be the focal point of utilization management and will advocate strongly against resistance.  Acts politely but is willing to have difficult conversations and is able to hold his/her ground in challenging situations


• Maintains patient confidentiality at all times


• Passionate about decreasing unnecessary healthcare utilization and improved financial performance


• Exhibits ownership of processes and projects  and relentlessly drives for excellent results


• Takes full ownership of the processes needed to reduce utilization and for the overall results of initiatives within his/her responsibility

Exemplifies Cigna Competencies

• Customer Focus


• Conflict Management


• Courage


• Motivating Others


• Interpersonal Savvy


• Informing

QUALIFICATIONS

• Unencumbered Registered Nurse licensure with a minimum of 2 years of experience in utilization management, Case Management, Care Coordination or related area


• CCM strongly preferred


• Utilization Review exp preferred


• 3-5 years work experience in inpatient, ED or critical care services preferred


• Preferred  minimum 2 years of formal or informal management of people and or processes


• Prefer candidates located in AZ but will consider qualified candidates from other states as well


• Thorough knowledge of current standards of patient care and utilization tools such as Milliman and Interqual


• Computer and Microsoft application proficiency


• Population Health Management experience that has resulted in appropriate utilization of services and knowledge of community services preferred


• Strong oral, written, and presentation skills required in order to represent the organization to internal and external customers


• Can show proof of success in the following areas:


• Ability to drive results with real examples of successes


• Good command of data management and development of data-driven processes that improve care, and/or decrease cost


• Basic knowledge of analytic tools and data management skills.


• Requires high-speed, broadband wired internet and to meet work-at-home requirements

SCOPE

• Position is responsible for implementing clinical programs that assist the department deliver on the Triple Aim and that directly impact utilization trends.


• Assists the Clinical Supervisor with responsibility for staff performance to program standards.


• This position is both transactional and operational in nature

This is a Work-at-home position

This position is not eligible to be performed in Colorado.

About Cigna

Cigna Corporation (NYSE: CI) is a global health service company dedicated to improving the health, well-being and peace of mind of those we serve. We offer an integrated suite of health services through Cigna, Express Scripts, and our affiliates including medical, dental, behavioral health, pharmacy, vision, supplemental benefits, and other related products. Together, with our 74,000 employees worldwide, we aspire to transform health services, making them more affordable and accessible to millions. Through our unmatched expertise, bold action, fresh ideas and an unwavering commitment to patient-centered care, we are a force of health services innovation.

When you work with Cigna, you’ll enjoy meaningful career experiences that enrich people’s lives while working together to make the world a healthier place. What difference will you make?  To see our culture in action, search #TeamCigna on Instagram.

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.