RN Nurse Community Case Manager

Cigna

(Houston, Texas)

Full Time Travel Required

Job Posting Details

About Cigna

At Cigna, we're more than a health insurance company. We're a global health service company.

Responsibilities

* Identifies high-risk/high-cost patients for possible case management intervention.
*  Interfaces with providers of medical services and equipment to facilitate effective communication, referrals, development of discharge planning, and alternative treatment plan development.
*  Identifies customer needs, coordinates and support planned and unplanned transitions and post discharge follow up calls which may include primary care physician and specialist appointment scheduling
* Initiates contact with patient/family, physician, and health care providers/suppliers to discuss the alternative treatment plan. Conducts on-site evaluations (customer home visits) as is necessary.
*  Documents all customer and provider contact, clinical notes, short term, long term and prioritize goals and revisions to the individual care plan in the integrated care management system
*  Collaborates with the attending physician to achieve identified patient outcomes.
*  Develop and implement individual care plans with customer
*  Communicate care plan with customer and physician
* Extends, revises or closes care plan goals as is appropriate.
*  Refers questionable case management cases or requests to the Medical Director
*  Communicates in writing to the appropriate parties regarding case management decisions.
* Communicates denial decisions to all appropriate parties following established guidelines, when dealing with a denied authorizations such as, but not limited to, out-of-network referrals
*  Evaluates each case for quality of care, documents quality issues and appropriately refers cases with questionable quality of care to the Manager of Quality Assurance.
*  Attend and participate in weekly Complete Health Team rounds
*  Perform telephonic outreach or home visits, as needed
*  Communicates with all departments to resolve issues or document trends.
*  Understands and follows administrative guidelines (policy and procedure) of the unit.
* Attends and actively participates in staff meetings.
*  Other Duties as assigned.

Identifies high-risk/high-cost patients for possible case management intervention.
Interfaces with providers of medical services and equipment to facilitate effective communication, referrals, development of discharge planning, and alternative treatment plan development.
Identifies customer needs, coordinates and support planned and unplanned transitions and post discharge follow up calls which may include primary care physician and specialist appointment scheduling
Initiates contact with patient/family, physician, and health care providers/suppliers to discuss the alternative treatment plan. Conducts on-site evaluations (customer home visits) as is necessary.
Documents all customer and provider contact, clinical notes, short term, long term and prioritize goals and revisions to the individual care plan in the integrated care management system
Collaborates with the attending physician to achieve identified patient outcomes.
Develop and implement individual care plans with customer
Communicate care plan with customer and physician
Extends, revises or closes care plan goals as is appropriate.
Refers questionable case management cases or requests to the Medical Director
Communicates in writing to the appropriate parties regarding case management decisions.
Communicates denial decisions to all appropriate parties following established guidelines, when dealing with a denied authorizations such as, but not limited to, out-of-network referrals
Evaluates each case for quality of care, documents quality issues and appropriately refers cases with questionable quality of care to the Manager of Quality Assurance.
Attend and participate in weekly Complete Health Team rounds
Perform telephonic outreach or home visits, as needed
Communicates with all departments to resolve issues or document trends.
Understands and follows administrative guidelines (policy and procedure) of the unit.
Attends and actively participates in staff meetings.
Other Duties as assigned.

Ideal Candidate

Current Licensure as a registered nurse, in the state of Texas in good standing.
Associates degree, diploma or B.S. in Nursing
Five (5) years recent experience in an acute-care environment, or
Two years (2) years recent experience in a case-management or utilization management position
Certified Case Manager preferred

Compensation and Working Conditions