About the role
Telephonic Nurse Clinical Reviewer -EviCore-Remote
Full time RN Role- Remote
Monday- Friday 12:30pm-9:00 pm EST (Required Shift)
Start Date: Monday, September 14th
Shift for this role is Monday- Friday 12:30pm-9:00 pm EST. Start time may vary based on your local time zone. The first 7 weeks of employment will be day shift for training purposes. In the future, shift may vary based on business need to any 8 hour shift between the hours of 7am in your local time zone – 10 pm EST, Monday – Friday. There are no scheduled absences allowed during training for this role.
The Clinical Reviewer will be responsible for:
All clinical certification activities, which include but are not limited to evaluating telephone, fax or WEB requests for authorization of clinical services from physician offices/and or imaging centers, comparing requests against established clinical protocols and authorizing services or referring requests for expert clinical review as appropriate.
Know and understand complex case specialties and case reviews.
Review clinical information submitted by providers to appropriate criteria and standards and makes decision to issue a review determination or to refer to physician review if criteria are not met.
Maintain current departmental standards related to productivity.
Train in clinical certification, utilization management, URAC and NCQA principles, policies, and procedures.
Prepare program correspondence as needed.
Serve as a resource for members calling for assistance.
Make outbound calls as required.
Refer provider and member complaints, and appeals to appropriate departments.
Maintain patient confidentiality in accordance with EviCore standards established in compliance with HIPAA and State regulations.
Provide outstanding customer service ensuring callers receive the highest possible service.
Run and analyze reports to ensure all tasks are completed in a timely fashion and meet regulatory requirements.
Assist team members in departmental chats, by phone and in person.
Act as training assistant when assigned.
Assist team members with questions, participates in team meetings. Can be assigned to projects to support the department as needed.
Performs related duties as required.
Essential Functions:
Must be able to sit through shift, demonstrate advanced proficiency in MS Office applications.
Excellent communication skills both verbal and written;
Excellent problem solving and customer service skills are required.
Must be self-directed and highly motivated with an ability to multi-task.
Excellent computer skills.
Must be able to hear and speak on the phone for an entire shift
Qualifications:
Associates Degree in Nursing required.
Current, unrestricted license as an RN in state of primary residence
Must have at least 1 year of acute care, managed care, ER, ICU experience or 2 years of clinical utilization management experience
If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.
For this position, we anticipate offering an hourly rate of 31 - 52 USD / hourly, depending on relevant factors, including experience and geographic location.
This role is also anticipated to be eligible to participate in an annual bonus plan.
At The Cigna Group, you’ll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you’ll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k), company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year, paid holidays, and leaves of absence. For more details on our employee benefits programs, click here.
About Evernorth Health Services
Evernorth Health Services, a division of The Cigna Group, creates pharmacy, care and benefit solutions to improve health and increase vitality. We relentlessly innovate to make the prediction, prevention and treatment of illness and disease more accessible to millions of people. Join us in driving growth and improving lives.
Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.
If you need a reasonable accommodation to complete the online application process, please email [email protected] for assistance. Please note that this email inbox is dedicated to accommodation requests only and cannot provide application updates or accept resumes.
The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.
Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.