Utilization Review Nurse (WAH Position)
Cigna - Nashville, TN

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Job Description

Summary Description of Position

The RN provides clinical review and decision-making following specific clinical coverage position criteria and established clinical guidelines for targeted health claims and customer and healthcare professional appeals. The nurse decision-making is based on Cigna's accepted clinical criteria sets, regulatory requirements, contractual benefits and specific customer medical circumstances. Coverage recommendations on claims and appeals that require further professional or committee review are referred to a medical director following established policies and regulatory requirements. Conducts clinical determinations and/or recommendations on both Pre-service and Post-service Inpatient and Outpatient services for failure to prior authorize per the customer’s plan requirements using clinical criteria, the appropriate Nurse empowerment and/or physician referral policies. Conducts clinical appeal reviews for both level 1 and level 2 healthcare professionals and facilities and highly regulated customer appeals.

Major Job Responsibilities
  • Applies the appropriate nationally established medical necessity clinical criteria guidelines and policies & procedures to render pre or post-service clinical decisions based on the customer’s clinical information, the targeted services according to the customer’s plan requirements, the nurse empowerment program and the applicable regulatory and credentialing body requirements; refers appropriately to medical directors when not empowered
  • Requests key information that could influence the outcome of an appeal decision when so directed by the national policy
  • Prepares detailed medical information summaries for designated Medical Directors and Same or Similar Specialist Reviewers (SSSR’s) and/or Same State Licensure (SSL) requirements
  • Exercises clinical judgment as to what type of SSSR/SSL is required; demonstrates knowledge of regulatory requirements as to when SSSR/SSL is required for each case
  • Completes clinical documentation within the clinical review documentation requirements on templates and/or systems using existing policies for all case reviews
  • Obtains required documentation such as the appropriate clinical guidelines, additional clinical records if needed and when required, and the benefit plan language (to include SPDs, GSAs or Benefit Access) needed to make appropriate clinical review determinations; works closely with the healthcare professionals and/or facilities or IPAs/Medical Groups to obtain and provide additional information as needed
  • Responsible for either communicating to the CASA all customer and healthcare professional/facility correspondence terms regarding medical claim review and appeal clinical determinations, or completing the correspondence themselves, either through the manual NAO/CNR generated letters (Adult Dependent Handicapped cases), Dallas manual letter team, or other automated letter systems
  • Conducts IP and OP clinical reviews on all failure to secure authorization claims per customer’s plan requirements
  • Assists the non-clinical staff in the review of eligibility requests for Adult Dependent Handicapped family members of already eligible customers using the National Policy for accounts requesting this service, and applying the criteria as outlined in the associated policies and job aids
  • Other duties as required to meet business needs of claim and/or appeal operating units, Service Center, Legal department, and Provider Services; acts as a clinical resource for the administrative appeals unit
  • Documents the clinical review process per the established policies and procedures in the required templates and/or electronic documentation systems
  • Takes an active role in care coordination (collaboratively works with matrix partners and providers in the customer’s on-going care), i.e., pre-service customer appeals
  • Quality clinical decisions and judgments are consistently made using the accurate application of nursing principles, clinical criteria, policies, benefits and regulatory requirements in the review of services for customers as submitted on claims, failure to authorize cases, and appeals, for medical necessity (which includes cosmetic and experimental/investigational/unproven) against the thorough clinical review and evaluation of submitted medical records
  • Demonstrates knowledge of healthcare product differences and contract differences by use of benefit and contracting information and appropriate application of this information to the customer’s specific product for review of targeted medical services on all referred claims and appeals
  • Understands and demonstrates the application of appropriate regulatory exceptions and requirements (examples: turnaround times, state coverage mandates for certain diagnoses, etc.) in the review of targeted medical services for customers in order to meet regulatory, credentialing and licensing requirements
  • Ensures standard clinical protocols are upheld by providing review of claims or appeals for targeted services using the appropriate resource tools as noted in the National Benefit Coverage Tool Policy
  • Meets productivity standards as defined by the NAO in order to meet customer expectations, effectively service our matrix partners and meet regulatory/quality credentialing/licensing requirements
  • Displays teamwork attitude by adapting to changes that improve efficiency and effectiveness of operations in the NAO
  • Contributes ideas to improve workflows within the organization and cross-functionally within the Claims Operations, Healthcare Facilitation Centers (HFCs) and other corporate entities
  • Alerts the Licensed Clinical Manager of any customer service issues in a timely manner
  • Provides feedback to the Claims Operations organization on the appropriate or inappropriate referral of claims for clinical review through defined channels of communication
  • Completes all required training per Cigna requirements and regulatory and credentialing body standards
  • Conducts oversight reviews of pre-service cases prepared by the LPN/LVNs per NAO policy
  • When requesting protected health information (PHI) from external or internal sources, employee limits requests for information to reasonably necessary information required to accomplish the intended purpose; accesses the minimum necessary amount of protected health information (PHI) needed to perform job functions; limits the health information disclosed to the amount reasonably necessary for its intended purpose on all routine or recurring disclosures of protected health information (PHI)

Reporting Relationship

The Utilization Review Nurse (RN) conducting retrospective clinical claim reviews and clinical appeals reviews reports to the Health Services Senior Specialist or Case Manager Senior Specialist (licensed clinical professional manager).

Minimum Requirements
  • RN active licensure
  • Three years clinical nursing experience required
  • Strong written and oral communication skills
  • Ability to effectively communicate with clinical and non-clinical personnel
  • Knowledge of state and regulatory standards
  • Managed Care, PPO and Indemnity Product knowledge
  • Strong time management and organizational skills
  • Ability to handle multiple duties with excellent prioritizing skills
  • Strong analytical skills
  • Proficient in the use of PC; strong keyboarding skills
  • Requires minimal direction on highly complex/sensitive issues

Preferred Requirements
  • One year or more experience in Managed Care preferred
  • One year or more experience in Utilization Management preferred
  • Case Management experience and certification (CCM) preferred


CIGNA - 19 months ago - save job
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Cigna (NYSE: CI) is a global health service company dedicated to helping people improve their health, well-being and sense of security. All...