Case Manager

Critical Tasks and Expected Contributions/Results:

• Manage the pre-authorisation process and claims by assessing proposed treatment and therapies for medical necessity, appropriateness and cost-effectiveness in accordance with relevant guidelines.

• Able to source and articulate said relevant guidelines while managing moderately-complex local to global level cases.

• Completes day-to-day Case Management tasks without immediate supervision, but has ready access to advice from more experienced team members.

• Use clinical knowledge to assess diagnosis and treatment plans and goals, and identifies gaps in care or risks for readmission or complications.

• Establish patient centric goals and interventions to meet the member’s needs.

• Coordinate care and interface with the member, family members/caregivers, and the healthcare team, as well as internal matrix partners.

• Establish a documented patient centric case management plan involving all appropriate parties (client, physician, providers, employers, etc), identifies anticipated case results/outcomes, criteria for case closure, and promotes communication within all parties involved.

• Work with Cigna physicians to evaluate complex cases and receive appropriate clinical expertise on diagnosis and treatment plans.

• Deliver to customers clinical programs including case management, chronic condition management, lifestyle coaching, pre assignment assessment and any other program delivered by global clinical operations.

• Maintain accurate workflow and process documents.

• Adhere to professional practice within scope of licensure and certification quality assurance standards and all case management policy and procedures.

• Participate in unit and corporate training initiatives and demonstrates evidence of continuing education to maintain clinical expertise and certification as appropriate.

• Participate in clinical projects to enhance our customer’s health and wellbeing.

• Play an active role towards Cigna´s digital transformation.

• Serve as clinical liaison to Clients.

• Balance business needs with patient advocacy.

Key Challenges/Anticipated Changes in Environment:

• Demonstrate sensitivity to emotionally distressed and culturally diverse situations, clients and customers.

• Manage/coordinate an active volume of cases by providing information and coordination to customers worldwide in a multicultural population.

• Coordinate care with other Cigna Case Managers around the world when a need for local or regional expertise is important for better care or to comply with regulations.

Developmental Value of Position:

• Gain experiences and knowledge within the insurance and healthcare industry

• Broad exposure to all aspect of business operations and to develop leadership/general management skills

• Continue to utilize and enhance healthcare knowledge while out of clinical setting

Experience/Knowledge, Education and Other Requirements:

• Medical related Bachelor’s degree

• Clinical knowledge to assess diagnosis and treatment plans and goals, and identifies gaps in care or risks for readmission or complications.

• Knowledge and experience in relevant Health Insurance fields is preferred.

Personal Competencies Required:

• Strong organizational and leadership skills

• Strong interpersonal and communication skills

• Demonstrates problem-solving and analytical skills.

• Ability to build excellent working relationships with staff, matrix partners, customers and providers

• Ability to act as an “advocate” for the customer while complying with internal Policies and procedures and contractual/legal compliance requirements

• Strong time management and prioritisation skills

• Enthusiastic with a positive attitude

• Ability to operate computer, proficient with Microsoft office products, call center software, and a variety of software.

About The Cigna Group