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Description
Position Scope:
Manages/Coordinates an active caseload of inpatient case management cases for CIGNA Health Care.
Uses clinical knowledge to assess inpatient admission level of care, treatment plan and goals, identified gasps or risk for readmission or complications and any barriers to discharge.
Establishes patient centric goals and interventions to meet the members needs while inpatient and post inpatient stay.
Interfaces with facility, member, family, and other healthcare team members as well as internal matrix partners.
Balances business needs with patient advocacy.
Builds solid working relationships with internal staff, matrix partners, key functional areas, customers, and providers.
Responsibilities
Major responsibilities and desired results:
Develops and defines a structured working relationship with key partners in inpatient facilities to support regular, effective communication and exchange of information in order to manage the members needs in compliance with all Federal/State/Facility contract and internal CIGNA requirements.
Retrieves active daily census each morning and prioritizes cases for impact.
Access the approved CIGNA guidelines for inpatient review and directs communication with the facility to elicit clinical information and facilitate discharge planning.
Identified all cases appropriate for inpatient case management interventions, initiates and discusses options for discharge planning with the facility, provider, vendor, member and/or family and documents interactions and outcomes related to those actions.
Identify and build effective relationships with a network of community, government, and knowledge resources. Maintain information on those resources and share with peers as appropriate.
Act as liaison and patient advocate between account, participant, family, physician(s) and facilities/agencies. Take appropriate action to ensure participant and practitioner satisfaction within benefit constraints.
Develop a participant centered plan for short term and long term objectives, including time frames for follow up. Utilize available internal and community resources in development of plan. Involve all appropriate parties (member, physician, providers, employers, etc) to determine case results/outcomes.
Provide information and resources as appropriate to empower participants to take an active role in care, treatment and cost decisions.
Implement, coordinate, monitor and evaluate the plan on a systematic, ongoing, appropriate basis.
Negotiate price and quality care levels, intensity and durations of services.
Document findings and continue to anticipate needs, determine benefit coverage status and communicate proactively to participant and members of treatment team.
Identifies new referrals for complex and specialty CM programs and coordinates transition to appropriate CM when necessary.
Identifies and elevates potential quality of care issues to CIGNA's Quality representatives for follow up determination.
Works to identify gaps in care and resolution of those identified and prevention of future gaps in care.
May be required to participate in customer and auditor visits.
Participates in special projects as deemed necessary.
Other duties as required and related to this role.
Qualifications
Minimum requirements:
RN with active license in state where RN resides or as required by state law for practice.
Must have 3 years clinical experience in inpatient, acute care or managed care setting
Preferred requirements:
Bachelors degree
Demonstrated ability to anticipate, plan, coordinate and organize.
Knowledge of community, state and federal resources.
Possession of a valid drivers license, proof of insurance, good driving record and reliable transportation.
Strong skills in teamwork, negotiation, conflict management, problem solving, and effective decision making.
Experience in medical management and case management in a managed care setting or hospital is highly desirable.
Ability to assess complex issues, recommend changes and resolve problems.
Strong computer knowledge and abilities.
Knowledge of managed care products and strategies.
Ability to work within changing business environment and balance business needs with patient advocacy.
Experience managing multiple projects in a fast paced matrix driven environment.
Effective at negotiation, teamwork and cooperative relations with diverse internal and external stakeholders.
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. Our benefits begin the first day of employment.
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:
19152740
Posted / Updated:
3/15/2010 3:52:31 AM
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