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

Cigna; Glendale (CA); Remote; USD 80,000 - 100,000; Full time

Job summary

A leading healthcare company is seeking a Nurse Case Manager to provide advanced case management services. The role involves planning and evaluating healthcare services, managing complex cases, and leading junior staff. The ideal candidate will have a strong clinical background and an RN license.

Qualifications

• Handles complex, high acuity cases and account-sensitive cases.
• Acts as a team leader for new tools or programs.
• Manages own caseload and guides junior staff.

Responsibilities

• Plans, implements, and evaluates health care services.
• Ensures case management program objectives are met.
• Performs reviews for inpatient acute care and referrals.

Skills

Clinical Skills

Case Management

Leadership

Education

RN License

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 the 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 select 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 case management programs. Manages own caseload, supports, and provides guidance to junior staff, and exercises judgment in evaluating and adapting techniques and procedures. Utilizes in-depth professional knowledge to develop models and monitor trends within Nurse Case Management. RN license required.