This position, the Case Manager Specialist, through the case management process, will promote the improvement of health outcomes to members and assist those members experiencing the burdens of illness and injury. The Case Manager will assess, plan, implement, coordinate, monitor and evaluate options and services to meet an individual’s health needs within case load assignments of a defined population based on business perspectives. The Case Manager will promote quality cost-effective outcomes managing care needs through the continuum of care utilizing effective verbal and written communication skills and a consumerism approach through education and health advocacy to members serviced. Ability to work independently and effectively communicate to internal and external customers in a telephonic environment..
Major responsibilities and desired results:
- Establishes a collaborative relationship with client (plan participant/member), family, physician(s), and other providers to determine medical history and current status and to assess the options for optimal outcomes.
- 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 evaluates the case management plan on an ongoing, appropriate basis.
- Negotiates price, level of care, intensity and duration with provider(s), as appropriate.
- Acts as a timely and proactive 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 professional practice within scope of licensure and certification quality assurance standards and all case management policy and procedures
- Compliant with all accreditation, State and Federal mandates
- Delivers utilization review services when member is in active case management as appropriate
- Participates in unit and corporate training initiatives and demonstrates evidence of continuing education to maintain clinical expertise and certification as appropriate.
- Demonstrates sensitivity to culturally diverse situations, clients and customers.
- Based on experience, may provide leadership, preceptor/mentorship, support and coverage to other case management staff and assist case managers in achieving positive outcomes and savings
Participates in committees, task forces and other company projects as assigned and other assigned tasks as deemed necessary to meet business needs.
Ideal candidate will offer:
- Thorough knowledge and understanding of health behavior change theories and their application.
- Proven administrative abilities, with strong computer and software application skills.
- Excellent interpersonal skills and the ability to work in a team environment
- Demonstrated ability to set priorities
- A high energy level and excellent written and oral communication skills are essential.
- Passion for health improvement of members
- A minimum of three (3) years of clinical experience
- Diverse Clinical experience preferred
- RN with current licensure, Bachelors degree preferred
- CCM certification strongly preferred
- Experience with direct member communication ( written and oral)
- Experience in telephonic counseling preferred
- Experience in health education and wellness coaching
Cigna is a global health service company, dedicated to helping the people we serve improve their health, well-being and sense of security....