Nurse Case Management Lead Analyst-Nurse Clinician - Accredo

Job Description Summary

The Nurse Clinician - RN 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.

JOB DUTIES:

• Conduct criteria reviews for commercial payers, Medicare, and Medicaid


• Provide prior authorization assistance, and denial appeal assistance


• Prepare and write medical necessity appeal letters for claim denials for commercial and government payers.


• Support all aspects of Patient Access and Revenue Cycle Management (PARCM), including clearance and reimbursement for multiple Therapeutic Resource Centers.

• Active, unencumbered Registered Nurse (RN) license in Pennsylvania


• High School Diploma or GED, plus 8+ years of relevant RN experience; or


• 5+ years of relevant RN experience with an ASN degree; or


• 2+ years of relevant RN experience with a BSN degree


• Case management experience preferred


• 5+ years of experience is preferred in prior authorization or utilization review and appeals


• Demonstrated proficiency with Microsoft Office software; basic database navigation


• Ability to multitask in both PC/Phone related tasks


• Ability to build strong working relationships with colleagues and customers


• Strong time management skills and the ability to prioritize work and meet deadlines


• Excellent verbal and written communication skills


• Ability to work Monday-Friday, 8am-5pm, Eastern time


• Adequate home internet access will be required in this role

• Case management experience preferred


• 5+ years of experience is preferred in prior authorization or utilization review and appeals


• Demonstrated proficiency with Microsoft Office software; basic database navigation


• Ability to multitask in both PC/Phone related tasks

SOFT SKILLS:.

• Ability to build strong working relationships with colleagues and customers


• Strong time management skills and the ability to prioritize work and meet deadlines


• Excellent verbal and written communication skills


• Ability to work Monday-Friday, 8am-5pm, Eastern time


• Adequate home internet access will be required in this role

• Communicates Effectively


• Collaborates


• Customer Focus


• Decision Quality


• Nimble Learning

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 75,300 - 125,500 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 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.

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