Nurse Case Management Lead Analyst - Accredo - Work at Home

Cigna Healthcare•Pennsylvania Work at Home, PA

3d•$77,500 - $129,100•Remote

About The Position

The Nurse Case Management Lead Analyst will provide advanced professional input to complex Nurse Case Management assignments and projects. This role involves planning, implementing, and evaluating appropriate health care services in conjunction with the physician treatment plan, handling more complex, high acuity cases, and/or account-sensitive cases involving the largest reserves. The analyst will utilize clinical skills to assess, plan, implement, coordinate, monitor, and evaluate options and services to facilitate appropriate healthcare outcomes for members. They will ensure that case management program objectives are met by evaluating the effectiveness of alternative care services and maintaining cost-effective, quality care. The position includes performing prospective, concurrent, and retrospective reviews for inpatient acute care, rehabilitation, referrals, and select outpatient services, and may involve reviewing initial liability disability claims to determine the extent and impact of the insured's medical condition, restrictions, limitations, and expected duration. The role also entails a leadership function on the team when implementing new tools or case management programs/initiatives, managing their own caseload, coordinating all assigned cases, and supporting/directing more junior professionals. The Lead Analyst works autonomously, requiring only expert-level technical support from others, and exercises judgment in evaluating, selecting, and adapting standard and complex techniques and procedures. They will utilize in-depth professional knowledge and acumen to develop models and procedures, and monitor trends within Nurse Case Management.

Requirements

Registered Nurse (RN) license in state of primary residence.
Proficiency with Microsoft Office; basic database navigation.
Ability to manage multiple priorities, work independently. and collaborate effectively across teams.

Nice To Haves

BSN preferred.
Compact nursing license preferred.
Minimum 2 years of nursing experience in prior authorizations or case management preferred.
Knowledge of pharmacy, pharmaceuticals, preferred.

Responsibilities

Provides advanced professional input to complex Nurse Case Management assignments/projects.
Plans, implements, and evaluates appropriate health care services in conjunction with the physician treatment plan.
Handles more complex, high acuity cases, and/or account sensitive cases involving largest reserves.
Utilizes clinical skills to assess, plan, implement, coordinate, monitor and evaluate options and services in order to facilitate appropriate healthcare outcomes for members.
Ensures that case management program objectives are met by evaluating the effectiveness of alternative care services and that cost effective, quality care is maintained.
Performs prospective, concurrent, and retrospective reviews for inpatient acute care, rehabilitation, referrals, and select outpatient services.
May review initial liability disability claims to determine extent and impact of insured's medical condition, medical restrictions and limitations and expected duration.
Performs leadership role on team when implementing new tools or case management programs/initiatives.
Manages own caseload and coordinates all assigned cases.
Supports and provides direction to more junior professionals.
Works autonomously, only requiring “expert” level technical support from others.
Exercises judgment in the evaluation, selection, and adaptation of both standard and complex techniques and procedures.
Utilizes in-depth professional knowledge and acumen to develop models and procedures, and monitor trends, within Nurse Case Management.