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

Cigna; United States; Remote; USD 85,000 - 110,000; Full time

Job summary

A leading healthcare company is seeking a Senior Analyst for RN Utilization Review. This role involves advanced case management, evaluating healthcare services, and managing complex cases. The successful candidate will work autonomously, requiring expert-level support and will play a leadership role in implementing new programs.

Qualifications

• Handles complex, high acuity cases.
• Manages own caseload and supports junior professionals.

Responsibilities

• Plans, implements, and evaluates healthcare services.
• Performs reviews for inpatient acute care and outpatient services.
• Exercises judgment in developing models and monitoring trends.

Skills

Clinical Skills

Judgment

Education

RN License

Job description

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

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 prospective, concurrent, and retrospective reviews for inpatient acute care, rehabilitation, referrals, and outpatient services. May review initial disability claims to determine the extent and impact of the insured's medical condition, restrictions, limitations, and expected duration. Performs leadership roles on teams when implementing new tools or case management programs. Manages own caseload and supports junior professionals. Works autonomously, requiring only expert-level support from others. Exercises judgment in selecting techniques and procedures, developing models, and monitoring trends within Nurse Case Management. Must hold an RN license and have a current unrestricted nursing license.