Major Job Responsibilities and Required Results Obtains informed verbal consent and takes all steps to obtain written consent. Establishes a collaborative relationship with the client (plan participant), family, physician(s), and other providers to determine medical history and current status to assess the appropriate level of care and options for alternative care. Sets a plan for short term and long term goals, time frames for follow-up, resources available (internal and community), involves all appropriate parties (client, physician, providers, employers, etc), and identifies anticipated case results/outcomes and criteria for case closure. Implements, coordinates, monitors and evaluates the case management plan on an ongoing basis in collaboration with the client and treating providers as appropriate. Negotiates fee for services, level of care, intensity and duration with providers(s), as able. 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) on an ongoing basis. Acts as liaison between account, client/family, physician(s) 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. Delivers utilization review services for all inpatient, outpatient, and home services throughout the duration of transplant case management services. Interacts and coordinates referrals to the Medical Directors as necessary. Acts as a preceptor for Case Managers for training and/or performance issue, as able and as assigned. Demonstrates evidence of continuing education, minimally 1 per quarter to maintain clinical expertise. The Specialty Case Manager interacts with benefit specialist and claims staff for claim payment direction to ensure correct interpretation of transplant contracts and to apply payments accurately. Assists in service marketing and/or account management functions for service center-based customers, as assigned. 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
At least one of the following (3) qualifications: A bachelor's degree in health related field and license ,a RN license or, RN licensure and 3 years clinical experience. CCM a plus. Practice within the scope of CM license.
Preferred Requirements -Clinical experience in acute or case management within a specialty area preferred. Including experience/expertise in one of the following selected nursing fields: Obstetrics, Pediatrics, Neonatology, Oncology/Hospice, Medical/Surgical, Transplant, Trauma, Cardiac, Home Health, and Rehab.
Demonstrated ability as a specialty case manager and ability to assist supervisor with sales/training/account service management. Excellent time management, organizational, research, analytical, negotiation, communication (verbal and written) and interpersonal skills. Expert knowledge of the insurance industry and claims processing. Service marketing/account management experience a plus. Computer skills and typing expertise.
CIGNA - 18 months ago
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With a significant position in the US health insurance market, CIGNA covers some 11.5 million Americans with its various medical plans. The...