Telephonic Registered Nurse Clinical Reviewer - EviCore

Job Overview

Telephonic Nurse Clinical Reviewer -EviCore-Remote Full time RN Role- Remote Monday- Friday 12:30pm-9:00 pm EST (Required Shift) Start Date: Monday, September 14th Shift for this role is Monday- Friday 12:30pm-9:00 pm EST.

Start time may vary based on your local time zone. The first 7 weeks of employment will be day shift for training purposes.

Job Description

In the future, shift may vary based on business need to any 8 hour shift between the hours of 7am in your local time zone – 10 pm EST, Monday – Friday. There are no scheduled absences allowed during training for this role.

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.

Key Responsibilities

• The Clinical Reviewer will be responsible for: All clinical certification activities, which include but are not limited to evaluating telephone, fax or WEB requests for authorization of clinical services from physician offices/and or imaging centers, comparing requests against established clinical protocols and authorizing services or referring requests for expert clinical review as appropriate.
• Train in clinical certification, utilization management, URAC and NCQA principles, policies, and procedures.
• Can be assigned to projects to support the department as needed.
• Performs related duties as required.
• Current, unrestricted license as an RN in state of primary residence Must have at least 1 year of acute care, managed care, ER, ICU experience or 2 years of clinical utilization management experience If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.
• At The Cigna Group, you’ll enjoy a comprehensive range of benefits, with a focus on supporting your whole health.

Required Skills and Qualifications

• Telephonic Nurse Clinical Reviewer -EviCore-Remote Full time RN Role- Remote Monday- Friday 12:30pm-9:00 pm EST (Required Shift) Start Date: Monday, September 14th Shift for this role is Monday- Friday 12:30pm-9:00 pm EST.
• Make outbound calls as required.
• Performs related duties as required.
• Essential Functions: 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 Qualifications: Associates Degree in Nursing required.

Benefits and Perks

• This role is also anticipated to be eligible to participate in an annual bonus plan.
• At The Cigna Group, you’ll enjoy a comprehensive range of benefits, with a focus on supporting your whole health.
• Starting on day one of your employment, you’ll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs.
• We also offer 401(k), company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year, paid holidays, and leaves of absence.
• For more details on our employee benefits programs, .
• About Evernorth Health Services Evernorth Health Services, a division of The Cigna Group, creates pharmacy, care and benefit solutions to improve health and increase vitality.

Work Location and Schedule

This role is listed as Remote USA with location information shown as Remote USA. The employment type is Full Time.

About the Company

The Cigna Group is the organization connected with this listing. USA Jobs Today displays this opportunity for job discovery only, so applicants should verify company details, application instructions, and eligibility on the official employer website.