Telephonic Nurse Clinical Reviewer

About Evernorth Health Services

Evernorth Health Services, a division of The Cigna Group, develops pharmacy, care, and benefit solutions designed to enhance health and vitality. We are dedicated to innovating and making the prediction, prevention, and treatment of illness and disease more accessible to millions.

Role Details

• Type: Full-time RN Role
• Location: Remote
• Required Shift: Monday-Friday, 12:30 PM - 9:00 PM EST. (Start time may vary based on local time zone.)
• Initial Training: First 7 weeks will be day shift for training purposes. No scheduled absences allowed during training.
• Future Shift Flexibility: May vary based on business needs to any 8-hour shift between 7 AM (local time) and 10 PM EST, Monday-Friday.

The Clinical Reviewer Will Be Responsible For:

• Performing clinical certification activities, including evaluating requests for authorization of clinical services via telephone, fax, or web from physician offices/imaging centers.
• Comparing requests against established clinical protocols and authorizing services or referring for expert clinical review as appropriate.
• Understanding and managing complex case specialties and reviews.
• Reviewing clinical information submitted by providers against appropriate criteria and standards to issue determinations or refer for physician review.
• Maintaining current departmental standards for productivity.
• Training in clinical certification, utilization management, URAC, and NCQA principles, policies, and procedures.
• Preparing program correspondence as needed.
• Serving as a resource for members seeking assistance.
• Making outbound calls as required.
• Referring provider and member complaints and appeals to appropriate departments.
• Maintaining patient confidentiality in accordance with EviCore standards, HIPAA, and State regulations.
• Providing outstanding customer service.
• Running and analyzing reports to ensure timely task completion and regulatory compliance.
• Assisting team members with departmental tasks via chat, phone, and in person.
• Acting as a training assistant when assigned.
• Assisting team members with questions and participating in team meetings.
• Supporting departmental projects as needed.
• Performing related duties as required.

Essential Functions:

• Ability to sit for the duration of the shift.
• Advanced proficiency in MS Office applications.
• Excellent verbal and written communication skills.
• Excellent problem-solving and customer service skills.
• Self-directed and highly motivated with the ability to multi-task.
• Excellent computer skills.
• Ability to hear and speak on the phone for an entire shift.

Qualifications:

• Associate's Degree in Nursing required.
• Current, unrestricted RN license in the state of primary residence.
• Minimum of 1 year of acute care, managed care, ER, or ICU experience, OR 2 years of clinical utilization management experience.

Technical Requirements for Remote Work:

• Internet connection must be cable broadband or fiber optic with speeds of at least 10Mbps download/5Mbps upload if working from home.

Compensation and Benefits:

• Hourly Rate: $31 - $52 USD per hour, depending on experience and location.
• Bonus: Anticipated eligibility for an annual bonus plan.
• Benefits: Comprehensive benefits package including medical, vision, dental, well-being and behavioral health programs, 401(k), company-paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year, paid holidays, and leaves of absence.

About The Cigna Group:

• The Cigna Group is committed to supporting the whole health of its employees and their families.
• Learn more about our benefits: https://jobs.thecignagroup.com/us/en/benefits

The Cigna Group is an equal opportunity employer. Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status, or any other characteristic protected by law.

Reasonable accommodations are available for applicants needing assistance with the online application process. Please email: seeyourself@thecignagroup.com.

The Cigna Group has a tobacco-free policy. Candidates in specific states where this is legally permissible may not be considered if they use tobacco/nicotine unless they enter a qualifying smoking cessation program prior to employment.