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Prior Authorization Nurse/Utilization Review Nurse - Must Reside in California, Virtual, California

Job typeFull Time
CountryUnited States
Position Scope
  • Analyze clinical information
  • Perform clinical reviews with focus on improved medical outcomes
  • Interact with participant and multiple members of the healthcare team
  • Interact with the medical director when unable to approve a request
  • Use of multiple systems and applications
  • Handle multiple products and benefit plans
  • Works under moderate direct supervision

Summary Description

Provides review of requests for outpatient and/or inpatient clinical services. Manages the provision of cost containment services by determining the medical necessity and appropriateness of setting and treatment, and channeling to network providers. Reviews cases for potential need for case management/Well Aware and makes referrals.
  • Utilizes effective communication, courtesy and professionalism in all interactions, both internally and externally. Assists and supports customer/account management processes as required.
  • Provides service delivery on assigned products in a manner consistent with established standard policies/procedures and customer result expectations. Requires performance on such things as:
    • Work with providers and participants to identify contracted providers for provision of services
    • Utilize established screening criteria to identify cases which require case management services
    • Evaluates medical information against criteria, benefit plan, and coverage policies and determines necessity for procedure and refers to Medical Director if criteria is not met
  • Adheres to quality assurance standards and all utilization management policies and procedures.
  • Serves as a resource to facilitate understanding of products
  • Handles some routine complaints; secures supervisory assistance with problem solving and decision making
  • Advises supervisory staff of any concerns or complaints expressed by providers, patients, insured, and customers
  • Attains established production standards and operational objectives including reviews/transactions completed per day, case documentation and telephone response requirements as established for this level
  • Performs additional unit duties below as appropriate:
    • Participate on special projects/customer demonstrations
    • Support and assist with training and precepting as required

- Interface with sales/account managers as appropriate to meet customer's needs.

Minimum Requirements
  • Active unrestricted Registered Nurse (RN) license in state or territory of the United States

Preferred Requirements
  • BSN preferred
  • Computer skills and typing expertise
  • Clinical experience in acute setting for 3 or more years utilization mgt exp
  • Excellent time management, organizational, research, analytical, customer service, communication (verbal and written) and interpersonal skills.
  • Ability to work in an automated environment
  • Ability to function as part of a team
  • Ability to multi-task
  • Knowledge of Utilization Management and Insurance Industry
  • Recent clinical or Utilization Review experience

This role is WAH which allows work to be performed at home. Employees must be fully vaccinated if they choose to come onsite. Currently we are encouraging all employee to remain working from home and all onsite meetings require a virtual option. Are you willing and able to comply with our policy?

About Cigna

Cigna Corporation exists to improve lives. We are a global health service company dedicated to improving the health, well-being and peace of mind of those we serve. Together, with colleagues around the world, we aspire to transform health services, making them more affordable and accessible to millions. Through our unmatched expertise, bold action, fresh ideas and an unwavering commitment to patient-centered care, we are a force of health services innovation. When you work with us, or one of our subsidiaries, you'll enjoy meaningful career experiences that enrich people's lives. What difference will you make?

Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.

If you require reasonable accommodation in completing the online application process, please email: SeeYourself@cigna.com for support. Do not email SeeYourself@cigna.com for an update on your application or to provide your resume as you will not receive a response.
Employer757 CIGNA HealthCare of CA, Inc.