Utilization Management Clinical Reviewer

Title: Utilization Management Clinical Reviewer (California) - Remote

remote type

Remote

locations

California Work at Home

time type

Full time

job requisition id

26010871

Job Description:

Utilization Management Clinical Reviewer (California) - Remote

Must currently reside and be a licensed RN in California

Hours: Monday-Friday. Must be able to work an 8-hour shift between 8:00 a.m.-5:00 p.m. PST.

In this role, you will manage an active caseload, assess clinical needs and levels of care, identify barriers to discharge, and coordinate safe transitions across the care continuum. You will collaborate with members, families, providers, facilities, and internal partners while balancing quality, affordability, benefit coverage, and member advocacy.

The role requires strong communication, organization, critical thinking, sound clinical judgment, and the ability to work independently in a remote environment. It also requires strong computer skills, including the ability to navigate multiple systems, document accurately, manage several tasks at once, and use technology effectively throughout the workday. This is a fast-paced role that may involve a high volume of inbound and outbound phone interactions while managing multiple priorities and documentation requirements.

Help improve health outcomes by guiding members through complex inpatient care. In this role, you will manage an active caseload, assess clinical needs and levels of care, identify barriers to discharge, and coordinate safe transitions across the care continuum. You will collaborate with members, families, providers, facilities, and internal partners while balancing quality, affordability, benefit coverage, and member advocacy.

Responsibilities

• Manage and coordinate an assigned caseload of complex, high-acuity, or account-sensitive inpatient cases.
• Complete prospective, concurrent, and retrospective clinical reviews for acute inpatient care, rehabilitation, referrals, select outpatient services, and durable medical equipment, as applicable.
• Apply approved clinical guidelines and tools to evaluate medical necessity, level of care, covered services, treatment goals, risk factors, and discharge needs.
• Review the daily census, prioritize cases, request relevant clinical information, and document decisions, interventions, and outcomes accurately and on time.
• Create member-centered short- and long-term care plans with measurable goals, follow-up timeframes, and clear criteria for transition or closure.
• Coordinate with members, families, physicians, facilities, vendors, caregivers, and internal partners to support timely discharge or transfer to the appropriate level of care.
• Identify and help resolve gaps in care, barriers to discharge, risk for readmission, and delays in services.
• Educate members about available benefits, care options, costs, and community resources so they can take an active role in health care decisions.
• Serve as a member advocate and liaison while working within benefit, regulatory, contractual, and program requirements.
• Escalate complex cases, quality-of-care concerns, and service delays to the appropriate manager, medical director, or Quality partner.
• Identify referrals for complex or specialty case management programs and coordinate a smooth transition when needed.
• Build effective relationships with internal teams, providers, customers, and community resources.
• Support customer or auditor visits, special projects, peer consultation, and other related duties as assigned.

Minimum Qualifications

• Active, unencumbered California RN licensure
• A minimum of two years of direct clinical RN experience in an inpatient or managed care setting

Preferred Qualifications

• Bachelor’s degree in nursing or a related field.
• Ability to assess complex clinical information, identify barriers, recommend solutions, and make sound decisions.
• Strong written and verbal communication, organization, time management, research, analytical, negotiation, and problem-solving skills.
• Ability to work independently, manage competing priorities, and collaborate in a fast-paced, matrixed environment.
• Proficiency using computers and clinical or case management systems.
• Experience in medical management, utilization management, or case management within a health plan or hospital setting.
• Knowledge of managed care products, care management strategies, and community, state, and federal resources.
• Demonstrated ability to anticipate needs, coordinate services, and build cooperative relationships with diverse internal and external partners.

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.

For this position, we anticipate offering an hourly rate of 31 - 52 USD / hourly, depending on relevant factors, including experience and geographic location.

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.

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. We relentlessly innovate to make the prediction, prevention and treatment of illness and disease more accessible to millions of people. Join us in driving growth and improving lives.

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.

Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.