Case Coordinator/LPN/Pre-Certification Coordinator (HealthSprin
Cigna - Nashville, TN

This job posting is no longer available on Cigna. Find similar jobs:Cigna jobs

Job Description Role Summary

Responsible for collaborating with healthcare providers and members to optimize member benefits and to promote effective use of resources. Assesses the medical necessity of outpatient and out of network services. May also manage appeals for services denied. May conduct pre-certification, concurrent and retrospective reviews to ensure compliance with medical policy, member eligibility, benefits, and contracts

. Responsibilities

Responsible for the effective and sufficient support of all utilization management activities to include prospective/ pre-certification review of outpatient medical services for medical necessity and appropriateness of setting according to established policies. Using an established set of criteria, evaluates and authorizes the medical necessity of outpatient services. Notifies provider of recommended changes in level of care. Evaluates cases for quality of care and documents quality issues. Issues letter to provider if the service meets certification criteria, and escalates to manager or Medical Director for review if the service does not meet certification criteria.

Hours: Mon-Friday . Position will primarily work day shift. However, there will be quarterly night meetings with providers.

Travel: Position involves occasional travel within Middle Tennessee and West Tennessee

. Requirements Qualifications

Minimum Requirements: *
  • Current TN unrestricted LPN licensure *
  • Previous clinical experience *
  • Time management and critical thinking skills a must *
  • Interpersonal skills and committment to customer service *
  • Must be a team player *
  • Must have initiative
Preferred Requirements: Current licensure as a Registered Nurse (RN). Managed care experience. Two years experience in utilization review. Knowledge of ICD-9 and CPT Coding guidelines. Managed care and physician's office experience is a plus