LPN/LVN or RN Nurse Case Management Senior Analyst- Work Onsite at Providers Office - Birmingham, AL (Jefferson County) at The Cigna Group

About the position The position involves coordinating and managing relationships with participating provider practices, ensuring that all customers in these practices meet quality metrics related to HEDIS and STAR performance measures. The role requires a detailed understanding of these metrics and the ability to develop and maintain processes that support quality healthcare delivery. The individual will be responsible for coordinating the delivery of cost-effective, quality-based healthcare services tailored to the individual needs of customers, their benefit plans, and available community resources. This includes planning, implementing, and evaluating appropriate healthcare services in conjunction with physician treatment plans. The role also involves utilizing clinical skills to assess, plan, implement, coordinate, monitor, and evaluate options and services to facilitate optimal healthcare outcomes for customers. The responsibilities include identifying gaps in quality metrics, maintaining a physical presence in provider practices, and identifying high-risk or high-cost patients for potential case management intervention. The individual will interface with medical service providers to ensure effective communication and facilitate referrals, discharge planning, and alternative treatment plan development. Additionally, the role requires coordinating customer needs, supporting transitions, and conducting follow-up calls post-discharge, which may involve scheduling appointments with primary care physicians and specialists. Collaboration with attending physicians to achieve patient outcomes is essential, as is participation in weekly Complete Health Team rounds. The position may also require telephonic outreach or home visits as needed, along with effective communication across departments to resolve issues or document trends. Adherence to administrative guidelines and active participation in staff meetings is expected, along with other duties as assigned.

Responsibilities

• Identifies gaps in needed quality metrics for customers and communicates to provider ,
• Maintains physical presence in participating provider practices ,
• Identifies high-risk/high-cost patients for possible case management intervention ,
• Interfaces with providers of medical services and equipment to facilitate effective communication, referrals, development of discharge planning, and alternative treatment plan development ,
• Identifies customer needs, coordinates and supports planned and unplanned transitions and post discharge follow up calls which may include primary care physician and specialist appointment scheduling ,
• Collaborates with the attending physician to achieve identified patient outcomes ,
• Attend and participate in weekly Complete Health Team rounds ,
• Perform telephonic outreach or home visits, as needed ,
• Communicates with all departments to resolve issues or document trends ,
• Understands and follows administrative guidelines (policy and procedure) of the unit ,
• Attends and actively participates in staff meetings ,
• Other Duties as assigned Requirements
• Current Licensure as a Registered Nurse in the state of Alabama in good standing ,
• Associates degree, diploma or B. S. in Nursing ,
• Three to Five (3-5) years recent experience in an acute-care environment, case-management or utilization management position ,
• Previous HEDIS and/or CMS STARs experience a plus ,
• Verbal and written communication skills ,
• Interpersonal skills ,
• Basic Mathematical and statistical ability ,
• Organizational skills ,
• Typing and computer knowledge - able to type 35WPM ,
• Knowledge of utilization review requirements and procedures ,
• Knowledge of current health care practices and appropriate treatments ,
• Knowledge of community resources ,
• Ability to travel to and work at participating provider offices ,
• Works independently with minimum of supervision Nice-to-haves
• Bilingual - preferred Spanish both conversational and written Benefits Apply Job!

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