RN Nurse Case Management Lead Analyst - Pathwell and Specialty Care Options (SCO) - Work from Home, California, USA

Please note: This position is open to Registered Nurses who are licensed and RESIDE in California.

Summary Description of Position

Manages a caseload of customers that require specialty drugs, evaluating the need for alternative services and as appropriate; assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual's healthcare needs. Through communication and available resources, the Case Manager promotes care coordination, provider collaboration, quality case outcomes, and provides quality, cost effective alternatives to care as appropriate. As an owner of cases, the Case Manager performs clinical review of medical specialty pharmacy services, coordinates transition of care, product rate negotiations, and accurately calculates medical cost savings. Case Managers performs case management evaluation to identify any clinical needs, social determinants of health needs, discuss programs and services available with referrals as appropriate, and coordinates care and closes gaps through collaboration with customers, treating physicians, and servicing providers.

• Obtains informed verbal consent from customers for case management services
• Establishes a collaborative relationship with the client (plan participant), family, physician(s), facilities, specialty pharmacies, and other providers to determine medical history and current status to assess the appropriate level of care and options for alternative care.
• Assistance in the identification of member health education needs through health assessment activities
• Utilization of health prevention guidelines and general health and wellness strategies to achieve goals in the overall health of members.
• Perform research on relevant topics in health promotion and disease prevention, as required for specific members
• Consult with and assist team members in cases where a member’s behavioral health or emotional issues are impacting their ability to set and/or achieve goals
• .
• Educate and refer members on available internal and external health resources
• Provides 1:1 telephonic coaching to members around their behavior change to improve health status, reduce health risks and improve quality of life. 
• Assesses readiness to change and implements actions to assist members in moving through stages of change to reach their goals
• Work with members to identify and set personalized health improvement plans and goals and support members in achieving those goals.
• Promote consumerism through education and health advocacy.
• Assesses member’s health status and treatment plan and identifies any gaps or barriers to healthcare. Establishes 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.
• Implements, coordinates, monitor and evaluate the case management plan on an ongoing, appropriate basis.
• Adheres to professional practice within scope of licensure and certification quality assurance standards and all case management policy and procedures
• Participates in unit and corporate training initiatives and demonstrates evidence of continuing education to maintain clinical expertise and certification as appropriate.
• Negotiates fee for services, level of care, intensity and duration with provider(s), as appropriate.
• Documents findings in a clear concise manner and continues to evaluate medical necessity of frequency, intensity and length of care with physician(s) and agency/vendor(s).
• Acts as liaison between account, client/family, physician(s), internal and external matrix partners, and facilities/agencies.
• Maintains accurate record (system) of case management interventions including cost/benefit analysis, savings, and data collection. Adheres to quality assurance standards and all case management policy and procedures.
• Interacts with the Medical Directors as necessary.
• Demonstrates evidence of continuing education, minimally 1 per quarter to maintain clinical expertise.
• The Case Manager interacts with Care Associates, benefit specialists, Cigna Coverage Review Department, Accredo Specialty Pharmacy, and claims staff for claim payment direction to ensure correct interpretation of current and future cost of care.
• Assists Sales Account Executive in communicating status and/or resolving issues for service center-based customers, as assigned.
• Participates on committees, task forces and other company projects, as assigned.
• Supports training initiatives or audits of case files, as assigned.
• Demonstrates sensitivity to culturally diverse situations, clients and customers.
• Any other assigned tasks as deemed necessary to meet business needs. 
• Ensures the member’s privacy, confidentiality, and safety are maintained, adheres to ethical and accreditation standards, serves as a member advocate, and adheres to legal and regulatory standards. 
• Ensures that care management program objectives are met by evaluating the effectiveness of alternative care services and that cost effective, quality care is maintained.
• Ensures that care management program objectives are met by evaluating the effectiveness of alternative care services and that cost effective, quality care is maintained.
• Performs care management for specialty programs in a telephonic customer- facing environment which involves utilizing a coaching approach that provides support and resources to the customers.

Minimum Requirements

* Unrestricted CALIFORNIA RN licensure required

* Incumbent must reside in the state of CALIFORNIA

* Requires three years of nursing patient care experience

* Must have access to high-speed broadband wired internet with a modem. Cigna cannot support hot spots or satellite-based internet

Preferred Qualifications

• Clinical experience in acute care or case management preferred. Including experience/expertise in high dollar cases or cases involving specialty pharmacy.
• Previous Specialty Pharmacy experience
• A high energy level and excellent written and oral communication skills are essential.
• Excellent time management, organizational, research, analytical, negotiation, communication (verbal and written) and interpersonal skills.
• Proficient with computers and ability to talk and type while on the phone
• Intermediate computer skills and proficient with Microsoft Office and Windows
• Must be able to work in a fast-paced and virtual environment
• Expert knowledge of the insurance industry, and knowledge of claims processing and specialty pharmacy.
• Ability to make decisions on what needs to be done based on clearly established guidelines
• Strong personal computer skills, MS word, Excel, Outlook experience, and Internet research desired
• Strong skills in the following areas:  teamwork, conflict management, assessment complex issues, ability to recommend changes and resolve problems through effective decision making
• Experience in medical management and case management in a managed care setting is highly desirable
• Knowledge of managed care products and strategies
• Certification as a case manager from the URAC-approved list of certification; or certification within 4 years of hire
• A bachelors (or higher) degree in a health or human services related field

Org Marketing Statement

At Cigna, we are committed to providing our customers with employee benefits, expertise and services that improve the health, well-being and productivity of their employees.   Cigna's people are the key to our success in a changing and increasingly competitive marketplace.   The collective skills, behaviors and work experiences of all Cigna employees enable us to make a real difference in the lives of our members.  We seek the most talented and creative minds in the industry to develop innovative solutions our customers value and consumers expect.

Pay Benefits Work Schedule

Cigna offers a competitive compensation and comprehensive benefits package including health and wellness benefits, 401k plan, and work/life balance programs, as well as opportunities for career growth and development.

How To Apply

We encourage you to complete all questions on the candidate profile if you wish to be considered for this opportunity.

EEO Statement

Cigna is an Equal Opportunity Employer

If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

For this position, we anticipate offering an hourly rate of 40 - 66 USD / hourly, depending on relevant factors, including experience and geographic location.

This role is also anticipated to be eligible to participate in an annual bonus plan.

We want you to be healthy, balanced, and feel secure. That’s why you’ll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you’ll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at Cigna Group.

About Cigna Healthcare

Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. Join us in driving growth and improving lives.

Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.

If you require reasonable accommodation in completing the online application process, please email: SeeYourself@cigna.com for support. Do not email SeeYourself@cigna.com for an update on your application or to provide your resume as you will not receive a response.

The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.

Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.