Telephonic Registered Nurse Clinical Reviewer - EviCore - Remote

The Cigna Group

1d•$31 - $52•Remote

About The Position

The Telephonic Nurse Clinical Reviewer role is a full-time, remote position within EviCore. This role is classified as a UM Clinical Reviewer Senior Analyst, a Band 3 Senior Contributor Career Track Role. The position involves evaluating requests for clinical services, comparing them against established protocols, and making authorization decisions or referring cases for expert review. The role requires maintaining productivity standards, training in utilization management principles, and providing customer service to members and providers. Responsibilities also include preparing correspondence, managing patient confidentiality, running reports, and assisting team members and management as needed.

Requirements

Associates Degree in Nursing required.
Current, unrestricted license as an RN in state of primary residence.
At least 1 year of acute care, managed care, ER, ICU experience or 2 years of clinical utilization management experience.
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.
Internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

Responsibilities

Evaluate telephone, fax, or WEB requests for authorization of clinical services from physician offices and/or imaging centers.
Compare requests against established clinical protocols.
Authorize services or refer requests for expert clinical review as appropriate.
Understand complex case specialties and case reviews.
Review clinical information submitted by providers against appropriate criteria and standards.
Make decisions to issue a review determination or 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.