Job Description

Hours: 8:00 a.m. to 4:30pm EST / 8:30 am to 5:00 pm EST

Summary Description of Position
Manages a caseload of specialty cases, evaluating the need for alternative services and as appropriate; assesses, plans implements, coordinates, monitors, and evaluates options and services to meet an individual\'s healthcare needs. Through communication and available resources, the Specialty Case Manager promotes quality case effective outcomes, and provides quality, cost effective alternatives to acute care. As an owner of cases with onsite needs, the Specialty Case Manager performs clinical review of services and coordinates all discharge planning needs.

Major Job Responsibilities and Required Results
Obtains informed verbal consent and takes all steps to obtain written consent.
Establishes a collaborative relationship with the client (plan participant), family, physician(s), and other providers to determine medical history and current status to assess the appropriate level of care and options for alternative care.
Sets a plan for short term and long term goals, time frames for follow-up, resources available (internal and community), involves all appropriate parties (client, physician, providers, employers, etc), and identifies anticipated case results/outcomes and criteria for case closure.

Implements, coordinates, monitors and evaluates the case management plan on an ongoing basis in collaboration with the client and treating providers as appropriate.

Negotiates fee for services, level of care, intensity and duration with providers(s), as able.

Documents findings in a clear concise manner and continues to evaluate medical necessity of frequency, intensity and length of care with physician(s) and agency/vendor(s) on an ongoing basis.

Acts as liaison between account, client/family, physician(s) and facilities/agencies.

Maintains accurate record (system) of case management interventions including cost/benefit analysis, savings, and data collection. Adheres to quality assurance standards and all case management policy and procedures.

Delivers utilization review services for all inpatient, outpatient, and home services throughout the duration of transplant case management services. Interacts and coordinates referrals to the Medical Directors as necessary.
Acts as a preceptor for Case Managers for training and/or performance issue, as able and as assigned.

Demonstrates evidence of continuing education, minimally 1 per quarter to maintain clinical expertise.

The Specialty Case Manager interacts with benefit specialist and claims staff for claim payment direction to ensure correct interpretation of transplant contracts and to apply payments accurately.

Assists in service marketing and/or account management functions for service center-based customers, as assigned.

Assists Sales Account Executive in communicating status and/or resolving issues for service center-based customers, as assigned. Participates on committees, task forces and other company projects, as assigned. Supports training initiatives or audits of case files, as assigned.

Demonstrates sensitivity to culturally diverse situations, clients and customers. Any other assigned tasks as deemed necessary to meet business needs.
Ensures the member\xe2\x80\x99s privacy, confidentiality, and safety are maintained, adheres to ethical and accreditation standards, serves as a member advocate, and adheres to legal and regulatory standards.

Minimum Requirements
Active unrestricted Registered Nurse (RN) license required
Clinical experience in acute or case management within Oncology or Hospice strongly preferred
Minimum of 3 years direct patient care experience required
Demonstrated ability as a specialty case manager and ability to assist supervisor with sales/training/account service management.
Excellent time management, organizational, research, analytical, negotiation, communication (verbal and written) and interpersonal skills.
Expert knowledge of the insurance industry and claims processing.
Service marketing/account management experience a plus.
Computer skills and typing expertise required
Must have high-speed broadband wired internet with a modem/router

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 70,400 - 117,300 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\xe2\x80\x99s why you\xe2\x80\x99ll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you\xe2\x80\x99ll 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 Group .

About Evernorth Health Services
Evernorth Health Services, a division of The Cigna Group, creates pharmacy, care and benefit solutions to improve health and increase vitality. We relentlessly innovate to make the prediction, prevention and treatment of illness and disease more accessible to millions of people. Join us in driving growth and improving lives.

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.

The Cigna Group 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.