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Description
This position is accountable for directing case management activities to control the costs of high-risk, high-cost cases. Specific responsibilities include, but are not limited to: identifying cost-effective protocols for high-risk, high-cost diagnoses; and, developing and administering guidelines for working with employees, employers, policyholders, healthcare providers, patients, and families to determine appropriate, cost-effective care plans.
Major Duties
Clinical Support - The individual supports the medical needs of the members within the defined benefit structure. Job responsibilities include but are not limited to, pre-departure outreach, disease management, case management and oversight of vendor monitoring activities;
Subject Matter Expert- The individual identifies clinical information from an international perspective for internal customers (populate international clinical toolbox (ICT)); participates in project development and sales presentations as appropriate .
Key Responsibilities:
Health Services and Wellness ( HSW) operates as a cross- trained unit, with all clinicians able to support clients across all products, locations, and medical needs, with a goal of having regional experts within the team
HSW provides criteria to assist in identifying appropriate cases for referral to CM and/ or vendor. CM cases include, but are not limited to, those members identified as high risk due to location, diagnoses, and other potential issues; from Cleveland Clinic`s assessment via a pre-departure condition management questionnaire; via Care Allies notification of transition to international location.
Case Manager receives referrals via non- clinical staff in HSW assigning to CM system. Case Manger will assess and accept/decline for case management per SOP.
CM supports assessment of high dollar cases as identified by Claims/ Underwriting. Eligibility and prior report activity are confirmed prior to referral for review. HSW provides review of history, prognosis and CM involvement during the quarterly Reinsurance review as well as ad hoc reviews
CM participates in Claims Exceptions process as needed, by identifying medical needs as they pertain to a cost benefit analysis
Requirements: The ideal candidate will be a Registered Nurse with 5 years clinical experience and 2 years insurance background- UM/ CM/ DCP. International experience recommended; bilingual preferred. strong communication skills, cultural sensitivity, problem- solving, creativity, flexibility, able to support flexible work schedule depending on case assignments. Familiarity with Word, MS office, Excel.
Key challenges: Case Management system in development and will require training and ramp up time. History of requests/ expectations from all facets of company.
Developmental value:
Pay Benefits Work Schedule
CIGNA offers a competitive compensation and comprehensive benefits package including health and wellness benefits, 401k plan, and work/life balance programs, as well as opportunities for career growth and development.
How To Apply
We encourage you to complete all questions on the candidate profile if you wish to be considered for this opportunity.
Details:
Job Id:
18603046
Posted / Updated:
4/20/2010 3:33:39 AM
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