Telephonic Registered Nurse Clinical Reviewer - EviCore - Remote

Cigna Healthcare•Tennessee Work at Home, TN

2d•$31 - $52•Remote

About The Position

The Telephonic Nurse Clinical Reviewer is a full-time RN role that is remote. The primary responsibility is to conduct clinical certification activities, which involve evaluating requests for authorization of clinical services received via telephone, fax, or web. This includes comparing requests against established clinical protocols, authorizing services, or referring requests for expert clinical review when necessary. The role requires maintaining current departmental standards for productivity, training in clinical certification, utilization management, URAC, and NCQA principles, policies, and procedures. Additionally, the reviewer will prepare program correspondence, serve as a resource for members, make outbound calls, refer complaints and appeals, maintain patient confidentiality in accordance with HIPAA and state regulations, provide outstanding customer service, and run/analyze reports to ensure timely completion of tasks and regulatory compliance. The role also involves assisting team members, acting as a training assistant when assigned, participating in team meetings, and supporting departmental projects as needed. Performs related duties as required.

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.
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.