Registered Nurse is responsible for reviewing escalated clinical criteria reviews for providers, members and patient client advocates within the Prior Authorization/Utilization Management department. Identify and track trends for analytics reporting to ensure clinical criteria program integrity. Maintain a professional and ethical behavior at all times as outlined by the Nurse Practice Act and applicable company policies.

ESSENTIAL FUNCTIONS

• Adheres to principles as stipulated by program specific contractual agreements and company practices which may include:

• Interact and build relationships with assigned patients throughout duration of program.

• Provide patient centric education regarding treatment and disease states for assigned products.

• Complete monthly appeals across both reimbursement and prior authorization processes, leveraging strong knowledge of payer guidelines, denial resolution strategies, clinical documentation review, and cross-functional collaboration.

• Deliver customized interactions based on patient’s needs.

• Participates in program specific customer meetings and training sessions.

• Participates in program specific orientation meetings and demonstrates clinical and systems competency on tests.

• Performs special projects and performs other duties as it pertains to specific contract performance

• Hours: Minimum of 16 hours/week; hours to be determined to meet business needs.

QUALIFICATIONS

• Registered Nurse (RN) license in state of primary residence.

• BSN preferred.

• Compact nursing license preferred.

• Minimum 2 years of nursing experience in prior authorizations or case management.

• Proficiency with Microsoft Office; basic database navigation.

• Knowledge of pharmacy, pharmaceuticals, life sciences, or healthcare business required.

• Ability to multitask in PC/Phone tasks.

• Teamwork and communication skills required.

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 hourly rate of 31 - 52 USD / hourly, depending on relevant factors, including experience and geographic location.

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 need a reasonable accommodation to complete the online application process, please email seeyourself@thecignagroup.com for assistance. Please note that this email inbox is dedicated to accommodation requests only and cannot provide application updates or accept resumes.

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.

Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.

Additional Information

Company: Cigna Healthcare

Location: Anywhere

Salary: $31-$52 per hour

Job ID:

Specialties: Case Manager, Prior Authorization

Required Licenses: RN

Experience Level: 1-3 years