Case Manager

at  The Cigna Group

KEY CHALLENGES/ANTICIPATED CHANGES IN ENVIRONMENT:

• Demonstrate sensitivity to emotionally distressed and culturally diverse situations, clients and customers.
• Manage/coordinate an active volume of cases by providing information and coordination to customers worldwide in a multicultural population.
• Coordinate care with other Cigna Case Managers around the world when a need for local or regional expertise is important for better care or to comply with regulations.

EXPERIENCE/KNOWLEDGE, EDUCATION AND OTHER REQUIREMENTS:

• Bachelor in Nursing
• Clinical knowledge to assess diagnosis and treatment plans and goals, and identifies gaps in care or risks for readmission or complications.
• Knowledge and experience in relevant Health Insurance fields is preferred.
• Necessary licenses and certifications for quality assurance standards and all case management policy and procedures

• Manage the pre-authorisation process and claims by assessing proposed treatment and therapies for medical necessity, appropriateness and cost-effectiveness in accordance with relevant guidelines.
• Able to source and articulate said relevant guidelines while managing moderately-complex local to global level cases.
• Completes day-to-day Case Management tasks without immediate supervision, but has ready access to advice from more experienced team members.
• Use clinical knowledge to assess diagnosis and treatment plans and goals, and identifies gaps in care or risks for readmission or complications.
• Establish patient centric goals and interventions to meet the member’s needs.
• Coordinate care and interface with the member, family members/caregivers, and the healthcare team, as well as internal matrix partners.
• Establish a documented patient centric case management plan involving all appropriate parties (client, physician, providers, employers, etc), identifies anticipated case results/outcomes, criteria for case closure, and promotes communication within all parties involved.
• Work with Cigna physicians to evaluate complex cases and receive appropriate clinical expertise on diagnosis and treatment plans.
• Deliver to customers clinical programs including case management, chronic condition management, lifestyle coaching, pre assignment assessment and any other program delivered by global clinical operations.
• Maintain accurate workflow and process documents.
• Adhere to professional practice within scope of licensure and certification quality assurance standards and all case management policy and procedures.
• Participate in unit and corporate training initiatives and demonstrates evidence of continuing education to maintain clinical expertise and certification as appropriate.
• Participate in clinical projects to enhance our customer’s health and wellbeing.
• Play an active role towards Cigna´s digital transformation.
• Serve as clinical liaison to Clients.
• Balance business needs with patient advocacy.