Cigna RN Nurse Case Manager Specialist/(Telephonic/Field) Houston, Texas in Houston, Texas



·Performs all utilization review activities according to Health Services policy and procedures. Conducts onsite/telephonic review as assigned to obtain required information.

·Evaluates and authorizes the medical necessity of inpatient and outpatient services as assigned by application of approved criteria and established policies and guidelines.

·Notifies hospital and/or provider of recommended changes in level of care when applying approved criteria and established policies and guidelines.

·Facilitates the movement of the member through the continuum of care in a proactive manner.

·Refers cases to the Medical Director/POD Medical Director as appropriate.

·Concurrently enters all information into the healthplan’s computer documentation system ensuring complete and accurate information per established policies and guidelines.

·Completes opportunity report concurrently and any other reports or request for information in a timely manner.

·Notifies hospital and/or providers of all denials and generates denial letters as directed by the Medical Director within assigned time frames.

·Evaluates each case for quality of care, documents quality issues and appropriately refers cases to the quality management coordinator

·Reviews selected claims and retrospective requests for certification and follow-up as necessary with HeatlhServicesSupervisor, Managerof Inpatient Utilization or Medical Director.

·Participates in education of providers regarding Health Services policies and procedures.

·Identifies and refers cases concurrently to CCIP or Rapid Response unit as appropriate and indicated in established policies and guidelines.

·Performs member/family interviews and assists in discharge plan development and coordination of care.

·Maintains strong working relations with internal and external customers. Presents all communication in a positive and professional manor.

·Acts as a liaison for the health plan with outside entities, including, but not limited to physicians, hospital, health care vendors and facility Case management Departments.

·Attends and actively participates in staff meetings and is responsible for reviewing information presented.

·Maintains confidentiality in all aspects of operations. Complies with Corporate, Federal, and State confidentiality standards to ensure the appropriate protection of member identifiable health information.

·Facilitates referrals for follow up care with delegated entities.

·Maintains strong working relationships with Health Plan Medical Directors, Inpatient Managers, POD Inpatient Medical Directors and POD administrators.

·Actively participates in network meetings as scheduled and requested.

·Activley participates in mandatory weekly CHT rounds

·Actively participates in identification of opportunities for improvement and assists with action plan development and problem resolution.

·Knowledgeable in workflow, productivity and timeliness standards for all programs services.

·Completes and meets minimal IRR and audit standards.

·Prepares report and conducts analysis of POD specific information & communication. Reviews these results with POD Inpatient Medical directors prior to Inpatient Utilization Manager Meetings.

·Attends and actively participates in assigned POD Inpatient Manager Meetings as scheduled.

·Available and responsive to health plan and facility partners during regularly scheduled business hours.

·Supports an environment which fosters teamwork, cooperation, respect, and diversity.Establishes and maintains positive communication and professional demeanor with coworkers, delegates, vendors and members at all times.Demonstrates and supports commitment to organizational and plan goals and objectives.

·Maintains all necessary educational requirements for required licensure and certifications.

·Performs other related duties and projects as assigned.

·Adheres to Organizational policies and procedures.

·Supports and carries out the Organizational Mission & Values.


·Registered Nurse graduated from an accredited Diploma, Associates Degree or Bachelor’s Degree Program.

·2-3 years clinical experience with at least 1-2 years in utilization review. Managed Care experience preferred.

·Knowledge of ICD-10 coding, CPT coding and Interqual guidelines for utilization review.

·Current and valid Texas Registered Nursing License required.

·Current Driver’s license with current auto insurance.

·Availability: flexible work schedule with ability to work weekends and cover evenings.

US Candidates Only : Qualified applicants will be considered for employment without regard to race, color, religion, national origin, sex, sexual orientation, gender identity, disability, veteran status. If you require a special accommodation, please visit our Careers website or contact us

Primary Location: Houston-Texas

Work Locations: 2900 North Loop West STE 1300 Houston 77092

Job: Med Mgt--Case Management

Schedule: Regular

Shift: Standard

Employee Status: Individual Contributor

Job Type: Full-time

Job Level: Day Job

Travel: No

Job Posting: Oct 11, 2016, 5:21:06 PM