Nurse Case Manager Specialist
Cigna - Plano, TX

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Job Description

Financial/Claim Management 35%
  • Receives claim referrals and assesses medical/disability status and reports within quality assurance time frames.
  • Monitors medical progress of claimants and reports on and plans for deviations from the normal recovery process/length of disability.
  • Evaluates timely activity and case development of an effective medical plan with the most appropriate outcome.
  • Routinely evaluates case studies to identify trends, issues, and concerns. Makes any necessary modifications.
  • Follows standards for quality and timeliness in meeting responsibilities and goal-oriented action plans. Provides input in the form of recommendations, facilitation, and process (when appropriate) in any occupation reviews, IME/FCE procedures, early assessments, initial reviews, ongoing medical management and special priority projects.
Customer Service/Focus 25%
  • Participates directly in customer service calls, visits, pre-sales, installations, and renewals.
  • Consistently anticipates and proactively addresses service-related issues/concerns within required time frame to meet customers' expectations.
  • Supports business retention by proactively becoming involved with customers to ensure complete customer satisfaction.
  • Proactively seeks potential rehabilitation candidates and establishes a relationship with customers that is caring, safe, and positive.
  • Provides continuous communication to team members and customers to share learnings and to ensure consistency.
  • Supports CIGNA Group Insurance initiatives for quality improvement, change, growth, and excellence in business practices.
Partnership/Teamwork 30%
  • Understands and is able to articulate claimant's perspective
  • Facilitates relations with and between Claim Examiners, business partners, and customers to develop claim strategies, reduce the total cost of disability in all forms and implement improvement opportunities.
  • Supports pricing and contract design by communication acquired information relative to employers (employee layoffs, mergers, staffing changes) to business partners.
  • Monitors and shares contract trends/performance and communicates to Claim Examiners and/or account Consultant to ensure the most effective and efficient contracts for customer.
  • Collaborates with health care providers and ill/injured employees to promote accountability for the appropriateness and status of treatment plan and length of disability.
  • Functions as a team member by contributing professional expertise, cooperation, action plans, and identification of opportunities where claims, economic, medical/clinical and/or occupational resources can be utilized for goal attainment.
  • Conducts ad hoc claim reviews when appropriate.
  • Consistently provides shared learning from claim management through post mortem process and communication vehicles.
  • Consistently recognizes and leverages individual contributions and perspectives of other team members. Supports and participates in team and individual coaching activities.
  • Collaborates with team members and business partners in identifying trends and opportunities for continuous claims innovation.
  • Proactively participates working within the team and balances candor and sensitivity to encourage the exchange of productive ideas.
  • Acts as an advocate for injured/ill individuals through the assessment, planning, coordination, collaborating, evaluating, and communication of objective information regarding the medical status and state of well being.
  • Acts as a medical resource person for staff; provides educational opportunities for staff through training, inservice, and sharing of resources on one-on-one or group forums, whichever is most efficient and effective.
Self Development/Learning 10%
  • Remains current with all CIGNA policies and procedures.
  • Identifies and develops career objectives and action plans by partnering with management, human resources and other available sources
  • Seeks every opportunity to accept challenges and developmental opportunities.
  • Maintains a current knowledge base on medical disability management and medical trends.
  • Maintains current nursing licensure and specialty certifications that are relevant to the professional credibility of the position..

  • Licensed Registered Nurse with current licensure in state of residency and state of employment. License must be current and without standing or pending censure by any state.
  • Psych experience required
  • Strong skills in medical assessment/medical record review.
  • Work experience in disability management, utilization management, discharge planning, pre-certification, and concurrent review, return to work planning or case management.
  • Able to solve problems, deal with complexity and concepts comfortably; utilizes analysis, experience and judgement to make effective decisions.
  • Ability to recognize opportunities and act upon them in an expedient and professional manner.
  • Demonstrated commitment to continuous improvement by participation in a learning environment to support a process that is most effective and efficient. Communicates information in a clear, concise, ant timely manner while using appropriate channels of communication. Demonstrates excellent interpersonal skills. Ability to learn new technical business and system skills quickly in addition to new industry, company and product knowledge.
  • Demonstrates the ability to function as an individual and a team member. Is willing to share information and resources.
  • Ability to develop comprehensive knowledge of CIGNA Group Insurance missions and values, structure, products, and marketing process.
  • Strong professional presentation
  • Ability to function in a team environment.
  • Work experience with insurance claims (workers' Compensation (desired), Disability Required), Group Health (Desired).
Desired Qualifications
  • Bachelor's degree in Nursing.
  • A minimum of 3-5 years clinical experience with strong clinical background in at least one or more of the following: Medical/Surgical Nursing, Occupational Health Nursing,
Rehabilitation Nursing, Psychiatric Nursing, Critical Care Nursing, Public Health Nursing
  • Official certification on one or more of the below fields of nursing: Obstetric/Gynecology Nursing, Rehabilitation Nursing, Oncology Nursing, Cardiac Nursing, Orthopedic Nursing, Occupational Nursing
  • Bilingual (English plus one other language -Spanish preferred)
  • Demonstrated ability to understand DMS's contribution to CIGNA Group Insurance profitability and the financial effects of decisions and operation expenses.
  • Ability to generate innovative ideas, approaches, and solutions while being flexible and adaptable despite the conflicting demands of the situation.
  • Certification(s) in Case Management, Disability Management Specialist or Rehabilitation Counselor..

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