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

Pinnacle Enterprise Risk Consulting Services, LLC; Glendale (CA); Remote; Full time

Job summary

A leading health services company is looking for a Nurse Case Manager to handle complex cases and coordinate care across healthcare providers. The ideal candidate will have an active RN license and several years of clinical experience. This position requires strong organizational and problem-solving skills, as well as the ability to advocate for patient-centered care. Join us to make a difference in the lives of our members and drive impactful healthcare outcomes.

Benefits

Health coverage

401(k)

Paid time off

Annual bonus eligibility

Qualifications

• Active unrestricted RN license in the U.S.
• 3+ years clinical experience in inpatient or managed care settings.
• Knowledge of community, state, and federal resources.

Responsibilities

• Manages and coordinates an active inpatient case management caseload.
• Plans and evaluates healthcare services aligned with physician treatment plans.
• Facilitates discharge planning and coordinates care across providers.

Skills

Organizational Skills

Negotiation Skills

Problem-Solving Skills

Education

Bachelor's degree

Tools

Computer Skills

Job description

Job Description Summary

Provides advanced professional input to complex Nurse Case Management assignments/projects. Plans, implements, and evaluates appropriate health care services in conjunction with the physician treatment plan. Handles more complex, high acuity cases, and/or account sensitive cases involving largest reserves. Utilizes clinical skills to assess, plan, implement, coordinate, monitor and evaluate options and services to facilitate appropriate healthcare outcomes for members. Ensures that case management program objectives are met by evaluating the effectiveness of care services and maintaining cost-effective, quality care. Performs reviews for inpatient acute care, rehabilitation, referrals, and outpatient services. May review initial liability disability claims to determine medical condition impact, restrictions, limitations, and 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. Exercises judgment in selecting techniques and procedures. Uses in-depth knowledge to develop models and monitor trends within Nurse Case Management. 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, and barriers to discharge.
• Establishes patient-centered goals and interventions for inpatient and post-inpatient care.
• Interfaces with facilities, members, families, healthcare team, and internal partners.
• Balances business needs with patient advocacy.
• Builds relationships with internal staff, partners, providers, and customers.

Summary of Responsibilities

• Plans, implements, and evaluates healthcare services aligned with physician treatment plans.
• Handles complex, high acuity, and account-sensitive cases.
• Performs reviews for inpatient and outpatient services, including DME.
• Ensures program objectives are met, evaluating care effectiveness and maintaining quality and cost efficiency.
• Works independently, managing own caseload and acting as a resource to others.
• Uses approved guidelines to assess clinical status and care appropriateness.
• Facilitates discharge planning and coordinates care across providers and caregivers.
• Consults with managers and medical directors to resolve service delays or barriers.

Major Responsibilities

• Develops relationships with inpatient facilities to support communication and member needs management.
• Prioritizes cases daily based on impact.
• Uses guidelines for inpatient review and communicates with facilities for clinical information and discharge planning.
• Identifies cases for intervention, discusses options, and documents interactions.
• Builds effective community and resource networks.
• Acts as liaison and advocate among members, providers, and facilities.
• Develops participant-centered care plans and involves relevant parties.
• Provides information to empower participants in their care decisions.
• Coordinates, monitors, and evaluates care plans systematically.
• Negotiates care levels and service durations.
• Documents findings and communicates proactively with the care team.
• Identifies new referrals and transitions to appropriate programs.
• Reports quality issues and works to prevent care gaps.
• Participates in audits, projects, and other duties as assigned.

Minimum Requirements

• Active unrestricted RN license in the U.S.

Preferred Requirements

• Bachelor's degree preferred.
• 3+ years clinical experience in inpatient or managed care settings.
• Strong organizational, negotiation, and problem-solving skills.
• Knowledge of community, state, and federal resources.
• Valid driver’s license and reliable transportation.
• Experience in medical and case management, especially in managed care or hospitals.
• Proficient computer skills and knowledge of managed care strategies.
• Ability to adapt to changing environments and manage multiple projects.

If working remotely, internet must be broadband (at least 10Mbps download/5Mbps upload). The hourly rate is anticipated to be $30-$50, depending on experience and location, with eligibility for an annual bonus. Benefits include health coverage, 401(k), paid time off, and more. For details, visit Life at Cigna Group.

About Evernorth Health Services

Evernorth creates pharmacy, care, and benefit solutions to improve health. Join us to drive growth and enhance lives.

We are an equal opportunity employer and consider all qualified applicants without regard to race, color, age, disability, sex, or other protected characteristics. Reasonable accommodations are available upon request at [e-mail]. We also have a tobacco-free policy and consider criminal histories in our hiring process.