Utilization Management Clinical Reviewer

Job not on LinkedIn

🔥 7 hours ago

🏄 California – Remote

🏄 California – Remote

💵 $31 - $52 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

🔍🏥 Medical Reviewer

👻 Ghost score 0%

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The Cigna Group

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1982

🏥 Healthcare

⚕️ Healthcare Insurance

💊 Pharmaceuticals

Healthcare • Healthcare Insurance • Pharmaceuticals

The Cigna Group is a global health company committed to improving the health and vitality of its clients, customers, and patients. With its two divisions, Cigna Healthcare and Evernorth Health Services, the company focuses on enhancing quality of life through healthcare services and pharmacy benefits management. The Cigna Group is dedicated to ethical practices in healthcare and artificial intelligence, and strives to create positive change in the healthcare system. It also emphasizes its Environmental, Social, and Governance (ESG) responsibilities, aiming to impact health equity and foster innovation in healthcare delivery.

📋 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 • Apply approved clinical guidelines and tools to evaluate medical necessity, level of care, covered services, treatment goals, risk factors, and discharge needs • Review 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 transition or closure criteria • 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 other assigned 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 • Ability to work an 8-hour shift between 8:00 a.m. and 5:00 p.m. PST, Monday-Friday • Internet connection through cable broadband or fiber optic service with at least 10 Mbps download and 5 Mbps upload for home work • 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

🏖️ Benefits

• Annual bonus plan eligibility • Medical insurance • Vision insurance • Dental insurance • Well-being and behavioral health programs • 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 requirement for home work