Critical Tasks and Expected Contributions/Results:
- 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.
Key Challenges/AnticipatedChanges 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.
Developmental Value of Position:
- Gain experiences and knowledge within the insurance and healthcare industry
- Broad exposure to all aspect of business operations and to develop leadership/general management skills
- Continue to utilize and enhance healthcare knowledge while out of clinical setting
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 ields is preferred.
- Necessary licenses and certifications for quality assurance standards and all case management policy and procedures
Personal Competencies Required:
- Strong organizational and leadership skills
- Strong interpersonal and communication skills
- Demonstrates problem-solving and analytical skills.
- Ability to build excellent working relationships with staff, matrix partners, customers and providers
- Ability to act as an “advocate” for the customer while complying with internal Policies and procedures and contractual/legal compliance requirements
- Strong time management and prioritisation skills
- Enthusiastic with a positive attitude
- Ability to operate computer, proficient with Microsoft office products, call center software, and a variety of software.
