RN Utilization Management Clinical Reviewer Senior Analyst - Work from Home, California

Cigna; United States; Remote; Full time

Job summary

A leading healthcare provider is seeking a Nurse Case Manager to oversee complex case management for patients. This role requires an active RN license and involves planning, implementing, and evaluating healthcare services, ensuring seamless care coordination and patient advocacy. Excellent organizational skills and a background in managed care are preferred, along with the ability to manage a caseload effectively. The position offers competitive pay and comprehensive benefits from day one.

Benefits

Health, dental, vision insurance

401(k) plan

Tuition reimbursement

Paid time off

Holidays

Annual bonus potential

Qualifications

• Active, unrestricted RN license in the U.S. required.
• 3+ years clinical experience in inpatient or managed care settings preferred.
• Strong negotiation, teamwork, problem-solving, and decision-making skills.

Responsibilities

• Plans, implements, and evaluates healthcare services aligned with physician treatment plans.
• Handles complex, high-acuity, and account-sensitive cases.
• Develops participant-centered care plans, involving all relevant parties.

Skills

Negotiation

Problem-Solving

Teamwork

Decision-Making

Time Management

Organization

Education

Bachelor’s degree

Tools

Computer proficiency

Job description

Job Description Summary

Provides advanced professional input to complex Nurse Case Management assignments/projects. Plans, implements, and evaluates appropriate healthcare services in conjunction with the physician treatment plan. Handles more complex, high acuity cases, and/or account-sensitive cases involving large reserves. Utilizes clinical skills to assess, plan, implement, coordinate, monitor, and evaluate options and services to facilitate appropriate healthcare outcomes for members. Ensures case management program objectives are met by evaluating the effectiveness of care services and maintaining cost-effective, quality care. Performs prospective, concurrent, and retrospective reviews for inpatient acute care, rehabilitation, referrals, and outpatient services. May review initial liability disability claims to determine the extent and impact of the insured's medical condition, restrictions, limitations, and expected duration. Acts as a team leader when implementing new tools or programs. Manages own caseload and supports junior professionals. Works autonomously with expert-level technical support. Uses in-depth professional knowledge to develop models, monitor trends, and improve Nurse Case Management practices. RN and current unrestricted nursing license required.

Position Scope:

• Manages and coordinates an active inpatient case management caseload for Cigna.
• Uses clinical knowledge to assess inpatient care levels, treatment plans, risks for readmission, and discharge barriers.
• Establishes patient-centered goals and interventions for inpatient and post-inpatient care.
• Interfaces with facilities, members, families, healthcare teams, and internal partners.
• Balances business needs with patient advocacy.
• Builds relationships with internal staff, partners, providers, and customers.

Summary of Position:

• Plans, implements, and evaluates healthcare services aligned with physician treatment plans.
• Handles complex, high-acuity, and account-sensitive cases.
• Performs reviews for inpatient, rehabilitation, referrals, outpatient services, including DME.
• Ensures program objectives are met, maintaining quality and cost-effectiveness.
• Requires excellent time management, organization, negotiation, research, and analytical skills. Knowledge of managed care preferred.
• Works independently, seeking guidance for new situations.
• Manages caseload, acts as resource, and uses guidelines to assess clinical status and care appropriateness.
• Facilitates timely discharge and transfer, consulting with managers and medical directors as needed.

Major Responsibilities:

• Develops relationships with inpatient facilities and manages communication for member needs.
• Prioritizes cases daily, assesses clinical information, and facilitates discharge planning.
• Builds community and provider resource networks.
• Acts as liaison and advocate, ensuring satisfaction and benefit compliance.
• Develops participant-centered care plans, involving all relevant parties.
• Implements, monitors, and evaluates care plans, negotiating services as needed.
• Documents interactions, identifies care gaps, and participates in quality and compliance activities.

Minimum Requirements:

• Active, unrestricted RN license in the U.S.
• Must reside in California.

Preferred Requirements:

• Bachelor’s degree preferred.
• 3+ years clinical experience in inpatient or managed care settings.
• Skills in planning, coordination, organization, and resource knowledge.
• Valid driver’s license, insurance, and reliable transportation.
• Strong negotiation, teamwork, problem-solving, and decision-making skills.
• Experience in medical and case management preferred.
• Computer proficiency and knowledge of managed care strategies.
• Ability to manage multiple projects in a fast-paced environment.

For remote work, internet must be broadband or fiber optic (≥10Mbps download/5Mbps upload). The hourly rate ranges from $30 to $50, depending on experience and location, with potential participation in an annual bonus plan.

We offer comprehensive benefits from day one, including health, dental, vision, 401(k), life insurance, tuition reimbursement, paid time off, and holidays. More info at Life at Cigna Group.

About Evernorth Health Services:

Evernorth, a division of The Cigna Group, provides pharmacy, care, and benefit solutions to improve health and vitality, innovating to make healthcare more accessible.

We are an equal opportunity employer, considering all qualified applicants regardless of race, color, age, disability, sex, or other protected characteristics. For accommodations, contact [e-mail]. We do not hire tobacco users in certain states due to company policies. Criminal history considerations are in accordance with law.