Unclassified

Cigna - Harlingen, TX

Full-time - Mid Level

Hybrid - Harlingen, TX

Insurance Carriers and Related Activities

About the position

The LVN/LPN or RN Nurse Case Management Senior Analyst is responsible for coordinating and managing relationships with participating provider practices, ensuring that all customers meet quality metrics related to HEDIS and STAR performance measures. This role involves developing and implementing alternative treatment plans tailored to individual customer needs, facilitating effective healthcare outcomes, and collaborating with healthcare providers to deliver cost-effective, quality-based health services.

Responsibilities

• Identifies gaps in needed quality metrics for customers and communicates to provider
• Maintains physical presence in participating provider practices
• 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 supports planned and unplanned transitions and post discharge follow up calls which may include primary care physician and specialist appointment scheduling
• Collaborates with the attending physician to achieve identified patient outcomes
• 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.

Requirements

• Current Licensure as a LPN/LVN or RN, in the state of Texas in good standing
• Associates degree, diploma or B.S. in Nursing
• Three to Five (3-5) years recent experience in an acute-care environment, case-management or utilization management position
• Previous HEDIS and/or CMS STARs experience a plus
• Bilingual - preferred Spanish both conversational and written
• Verbal and written communication skills
• Interpersonal skills
• Basic Mathematical and statistical ability
• Organizational skills
• Typing and computer knowledge- able to type 35WPM
• Knowledge of utilization review requirements and procedures
• Knowledge of current health care practices and appropriate treatments
• Knowledge of community resources
• Ability to travel to and work at participating provider offices
• Works independently with minimum of supervision.

Nice-to-haves

• Bilingual - preferred Spanish both conversational and written

Benefits

• Health insurance
• Paid time off
• Professional development opportunities
• Flexible scheduling options