Nurse Case Management Senior Analyst

工作職責

Job Responsibilities: - Support the pre-authorization process and claims by assessing proposed treatment and therapies for medical necessity, appropriateness and cost-effectiveness in accordance with relevant guidelines. - Able to source and articulate said relevant guidelines while managing local to global level cases - Use clinical knowledge to assess diagnosis and treatment plans and goals, and identifies gaps in care or risks for readmission or complications. - Establish patient centric goals and interventions to meet the member's needs. - Coordinate care and interface with the member, family members/caregivers, and the healthcare team, as well as internal matrix partners. - Establish a documented patient centric case management plan involving all appropriate parties (client, physician, providers, employers, etc), identifies anticipated case results/outcomes, criteria for case closure, and promotes communication within all parties involved. - Work with Cigna physicians and senior Case Managers to evaluate cases and receive appropriate clinical expertise on diagnosis and treatment plans. - Deliver to customers clinical programs including case management, chronic condition management, lifestyle coaching, pre assignment assessment and any other program delivered by global clinical operations. - Maintain accurate workflow and process documents. - Adhere to professional practice within scope of licensure and certification quality assurance standards and all case management policy and procedures. - Participate in unit and corporate training initiatives and demonstrates evidence of continuing education to maintain clinical expertise and certification as appropriate. - Participate in clinical projects to enhance our customer's health and wellbeing. - Play an active role towards Cigna's digital transformation. - Serve as clinical liaison to Clients. - Balance business needs with patient advocacy. Experience/Knowledge, Education and Other Requirements: - Bachelor's in nursing - Clinical knowledge to assess diagnosis and treatment plans and goals, and identifies gaps in care or risks for readmission or complications - Necessary licenses and certifications for quality assurance standards and all case management policy and procedures - Strong organizational and leadership skills - Strong interpersonal and communication skills - Demonstrates problem-solving and analytical skills. - Ability to build excellent working relationships with staff, matrix partners, customers and providers - Ability to act as an "advocate" for the customer while complying with internal Policies and procedures and contractual/legal compliance requirements - Strong time management and prioritization skills - Enthusiastic with a positive attitude - Ability to operate computer, proficient with Microsoft office products, call center software, and a variety of software.