Post Service UM Case Management Lead Analyst - Behavioral Health - Evernorth at Cigna in Bloomfield, Connecticut

Job Description:

The ideal candidate for this position is a licensed professional with a background in the insurance industry as a care manager in a behavioral healthcare role, or a Utilization Review RN with a behavioral background and/or experience, or an individual who has worked in a mental health or chemical dependency treatment facility in the area of utilization management.

The Post Service UM Case Management Lead Analyst conducts retrospective clinical claim reviews and clinical appeal reviews for targeted health claims and customer and healthcare professional appeals. The clinician decision-making for these reviews follows specific clinical coverage position criteria and established clinical guidelines and is based on the organization's accepted clinical criteria sets, regulatory requirements, contractual benefits and specific customer circumstances. Coverage recommendations on claims and appeals that require further professional or committee review are referred to a medical director following established policies and regulatory requirements.

Responsibilities:

• Conducts clinical determinations and/or recommendations on Post-service treatment at all levels of care per the customer's plan requirements using clinical criteria, the appropriate clinician empowerment and/or physician referral policies.


• Determines whether services provided to plan members were medically necessary following a thorough review of submitted medical records and case documentation from all available internal resources.


• Conducts clinical appeal reviews for both level 1 and level 2 healthcare professionals and facilities and highly regulated customer appeals.


• Delivers specific delegated tasks assigned by Supervisor.


• Develops and maintains knowledge of provider organization review procedures.


• Completes day-to-day utilization review tasks without immediate supervision, but has ready access to advice from more experienced team members.


• Work in a team environment which includes contributing to team meetings, collaborating with Evernorth Medical Directors for input on utilization management, supporting and assisting peers and Supervisor as needed, and attending all required trainings impacting utilization review and accreditation procedures.


• Resolve non-routine escalated issues as needed.


• Perform additional tasks/projects as needed, requested or assigned.

Qualifications

• Requires Master's degree in mental health discipline and independent licensure to practice in the state of employment (LCSW, LMFT, LPC, LPCC, Licensed Psychologist) with 3-5 years post-license mental health experience preferred or a valid RN licensure in the state of residency and 1 year of nursing experience required and 2 years of clinical experience preferred.


• Ability to work in a virtual environment while efficiently and effectively managing tasks that involve a degree of forward planning and anticipation of needs/issues.


• Must function well both independently and as part of a team.


• Excellent communication and interpersonal skills with a focus on customer service.


• Effective conflict management and negotiation skills.


• Ability to adapt to change and problem solve.


• Strong time management and organization skills with an ability to set priorities in a fast paced environment.


• Ability to utilize and navigate multiple technology systems.


• Knowledge of managed care preferred.

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 annual salary of 62,400 - 104,000 USD / yearly, 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 .

About Evernorth

Evernorth, Cigna Corporation's health services segment, exists to elevate health for all. We're building on our legacy and redefining health care as we know it. Unbiased in how we think, we create without limitation. We partner without constraints, deliver value differently and act in the interest of humanity. Solving across silos, closing gaps in care, and empowering clients, customers, and people everywhere to move onward and upward. When you work with us, you'll be empowered to solve the problems others don't, won't or can't. Join us. What difference will you make?

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.

Cigna 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.