Critical Tasks and Expected Contributions/Results:
Manage the pre-authorisation process and claims by assessing proposed treatment and therapies for medical necessity, appropriateness and cost-effectiveness in accordance with relevant guidelines.
Able to source and articulate said relevant guidelines while managing moderately-complex local to global level cases.
Completes day-to-day Case Management tasks without immediate supervision, but has ready access to advice from more experienced team members.
Use clinical knowledge to assess diagnosis and treatment plans and goals, and identifies gaps in care or risks for readmission or complications.
Establish patient centric goals and interventions to meet the members needs.
Coordinate care and interface with the member, family members/caregivers, and the healthcare team, as well as internal matrix partners.
Establish 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.
Work with Cigna physicians to evaluate complex cases and receive appropriate clinical expertise on diagnosis and treatment plans.
Deliver to customers clinical programs including case management, chronic condition management, lifestyle coaching, pre assignment assessment and any other program delivered by global clinical operations.
Maintain accurate workflow and process documents.
Adhere to professional practice within scope of licensure and certification quality assurance standards and all case management policy and procedures.
Participate in unit and corporate training initiatives and demonstrates evidence of continuing education to maintain clinical expertise and certification as appropriate.
Participate in clinical projects to enhance our customers health and wellbeing.
Play an active role towards Cigna´s digital transformation.
Serve as clinical liaison to Clients.
Balance business needs with patient advocacy.
Key Challenges/Anticipated Changes in Environment:
Demonstrate sensitivity to emotionally distressed and culturally diverse situations, clients and customers.
Manage/coordinate an active volume of cases by providing information and coordination to customers worldwide in a multicultural population.
Coordinate care with other Cigna Case Managers around the world when a need for local or regional expertise is important for better care or to comply with regulations.
Developmental Value of Position:
Gain experiences and knowledge within the insurance and healthcare industry
Broad exposure to all aspect of business operations and to develop leadership/general management skills
Continue to utilize and enhance healthcare knowledge while out of clinical setting
Experience/Knowledge, Education and Other Requirements:
Bachelor in Nursing
Clinical knowledge to assess diagnosis and treatment plans and goals, and identifies gaps in care or risks for readmission or complications.
Knowledge and experience in relevant Health Insurance fields is preferred.
Necessary licenses and certifications for quality assurance standards and all case management policy and procedures
Personal Competencies Required:
Strong organizational and leadership skills
Strong interpersonal and communication skills
Demonstrates problem-solving and analytical skills.
Ability to build excellent working relationships with staff, matrix partners, customers and providers
Ability to act as an advocate for the customer while complying with internal Policies and procedures and contractual/legal compliance requirements
Strong time management and prioritisation skills
Enthusiastic with a positive attitude
Ability to operate computer, proficient with Microsoft office products, call center software, and a variety of software.
About The Cigna Group
Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. Join us in driving growth and improving lives.
