Nashville, United States
6 months ago
The Nurse is responsible for supporting the Medical Director and Director of Pre-Certification. Responsibilities include assuring health care services are available to Cigna HealthSpring members in an appropriate cost-effective manner and delivery of those services to promote healthy outcomes.
Essential Duties and Responsibilities:
Responsibilities include collecting, analyzing, and evaluating clinical documentation received using established criteria to determine appropriateness of clinical decisions; Meet/exceed service level goals (e.g., Grade of Service, Average Handle Time, Average Speed to Answer, Abandonment Rate); Adherence to regulatory and departmental timeframes for review of requests received; Collaborates with the Medical Director to identify utilization trends and generation of monthly written reports;
Process approval and adverse clinical determination correspondence for members related to Prospective request for services. Initiate the letter of agreement process, working with Network Management to ensure Service Level Agreements are completed in a timely manner when applicable; Proficient knowledge of Health Services policies and procedures, Medicare, HIPPA and NCQA standards; Professional demeanor and the ability to work effectively within a team or independently; Flexible with the ability to shift priorities when required; Coordinates with member, family, and caregivers to help resolve barriers to care; Successfully collaborates with member and family to assure comprehension of available resources; Other duties as required