Nashville, United States
6 months ago
Summary:Performs utilization management duties for Cigna-HealthSpring members following national and state clinical guidelines for inpatient and outpatient Medicare and Medicaid covered services.Participates in the discharge planning process and identifies appropriate resources both internal and external required for a successful transition of care to an alternative setting.
Responsible for the effective and sufficient support of all behavioral utilization activities for several markets according to policies and procedures. Will focus on utilization management of Medicare and Medicaid covered Behavioral Health requests. Refers cases to the Medical Director as appropriate. Evaluates and refers cases to quality of care, disease management, and case management programs as needed. Assists with discharge planning. Maintains strong working relationship with internal and external customers. Professionally communicates information as needed or required. Documents information into the clinical management system. Supports the Cigna-HealthSpring Behavioral Health Unit providing data and identifying improvement opportunities.
This role will focus on the discharge process from Inpatienthospitalization.