Job Description

Summary description of position

This position through the case management process will promote the improvement of clinical outcomes to members and assist those members experiencing illness and injury. The Clinical 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 Clinical Case Manager will provide customers and clients with assistance to include " Information, Navigation and Coordination" to best meet the customers medical needs with regards to the covered benefit plan. Assistance may include such activities as providing clinical information regarding medical conditions or treatments, identifying providers and coordinating complex care plans . The Clinical 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 using different channels (videoconferencing and international phone calls)

Position Scope:

Manages/coordinates an active caseload of case management cases by providing Information, Navigation and Coordination to Customers outside the United States.

Major responsibilities and desired results:

Uses clinical knowledge to assess the treatment plan and goals, and identifies gaps in care or risks for readmission or complications.

Establishes patient centric goals and interventions to meet the member's needs

Interfaces with the member, family members/caregivers, and the healthcare team/provider, as well as internal matrix partners.

Balances business needs with patient advocacy by avoiding non-medically necessary tests and procedures to our customers.

Build solid working relationships with internal staff, matrix partners, key functional areas, customers, and providers

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

Assists Utilization Review as needed/ requested

Minimum requirements:

Nurse Licensure.

Experience in Utilization Management and Case Management.

Language skills: English and a second of the following languages required: Spanish, Portuguese, French, German, Arabic, Japanese, Mandarin or any Indian language.

Demonstrated strong organizational and leadership skills

Strong interpersonal and communication skills

Demonstrates problem-solving and analytical skills.

Knowledge of utilization or case management, cost containment services, managed care, insurance coverage, and financial management

Ability to act as an "advocate" for the customer while complying with internal Policies and procedures and contractual/legal compliance requirements

Ability to operate personal computer, proficient with Microsoft office products, call center software, and a variety of software.

Ability to build solid working relationships with staff, matrix partners, customers and providers

Not being under any warning.

Obtains informed verbal consent and takes all steps to obtain written consent as appropriate.

Support to Care Senior Associate Team as needed telephonically

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.

Provide international customer base with " assistance " support including; "Information, Navigation and Coordination" through customer advocacy, provider identification, assistance with health care coordination and healthcare navigation though use of internal resources and global clinical team.

Assesses member's health status and treatment plan and identifies any gaps or barriers to healthcare. Establishes a documented patient centric and evidence based 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 evaluate 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.

Maintains accurate workflow and process documents

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, Federal and local 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.

About Cigna

Cigna Corporation exists to improve lives. We are a global health service company dedicated to improving the health, well-being and peace of mind of those we serve. Together, with colleagues around the world, we aspire to transform health services, making them more affordable and accessible to millions. Through our unmatched expertise, bold action, fresh ideas and an unwavering commitment to patient-centered care, we are a force of health services innovation. When you work with us, or one of our subsidiaries, you'll enjoy meaningful career experiences that enrich people's lives. What difference will you make?