Utilization Management Clinical Reviewer

Job not on LinkedIn

🔥 15 minutes ago

🏄 California – Remote

🏄 California – Remote

💵 $31 - $52 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

🔍🏥 Medical Reviewer

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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The Cigna Group

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

🛡️ Insurance

Healthcare • Insurance

The Cigna Group is a global health services company that provides medical, dental, pharmacy, behavioral and supplemental insurance products and benefits to individuals, families, employers, brokers, providers and Medicare beneficiaries. It offers employer-sponsored group plans, individual and family plans (including Open Enrollment offerings), Medicare, international health insurance covering more than 200 countries, and digital member services through the myCigna platform (including telehealth and claims management). Its products are delivered through operating subsidiaries such as Cigna Health and Life Insurance Company and other regional affiliates.

📋 Description

• Manage and coordinate an assigned caseload of complex, high-acuity, or account-sensitive inpatient cases • Complete prospective, concurrent, and retrospective clinical reviews for acute inpatient care, rehabilitation, referrals, select outpatient services, and durable medical equipment, as applicable • Apply approved clinical guidelines and tools to evaluate medical necessity, level of care, covered services, treatment goals, risk factors, and discharge needs • Review the daily census, prioritize cases, request relevant clinical information, and document decisions, interventions, and outcomes accurately and on time • Create member-centered short- and long-term care plans with measurable goals, follow-up timeframes, and criteria for transition or closure • Coordinate with members, families, physicians, facilities, vendors, caregivers, and internal partners to support timely discharge or transfer • Identify and help resolve gaps in care, barriers to discharge, readmission risk, and service delays • Educate members about benefits, care options, costs, and community resources • Serve as a member advocate and liaison within benefit, regulatory, contractual, and program requirements • Escalate complex cases, quality-of-care concerns, and service delays to managers, medical directors, or Quality partners • Identify referrals for complex or specialty case management programs and coordinate transitions • Build relationships with internal teams, providers, customers, and community resources • Support customer or auditor visits, special projects, peer consultation, and related duties

🎯 Requirements

• Must currently reside in California • Active, unencumbered California RN licensure • Minimum of two years of direct clinical RN experience in an inpatient or managed care setting • Bachelor’s degree in nursing or a related field (preferred) • Ability to assess complex clinical information, identify barriers, recommend solutions, and make sound decisions • Strong written and verbal communication, organization, time management, research, analytical, negotiation, and problem-solving skills • Ability to work independently, manage competing priorities, and collaborate in a fast-paced, matrixed environment • Proficiency using computers and clinical or case management systems • Experience in medical management, utilization management, or case management within a health plan or hospital setting • Knowledge of managed care products, care management strategies, and community, state, and federal resources • Demonstrated ability to anticipate needs, coordinate services, and build cooperative relationships with diverse internal and external partners • Must be able to work an 8-hour shift between 8:00 a.m. and 5:00 p.m. PST, Monday-Friday • Home internet connection must use cable broadband or fiber optic service with at least 10 Mbps download and 5 Mbps upload

🏖️ Benefits

• Annual bonus plan eligibility • Medical, vision, and dental benefits starting on day one • Well-being and behavioral health programs starting on day one • 401(k) • Company-paid life insurance • Tuition reimbursement • Minimum of 18 days of paid time off per year • Paid holidays • Leaves of absence • Remote work arrangement • Cable broadband or fiber optic internet service requirement for home working