RN Quality Clinical Management Lead Analyst, Work from Home, Anywhere, USA (cigna)

Job Description

Major Duties and Responsibilities:

• Reviews and investigates potential quality of care (QOC) cases, which include, but are not limited to, adverse events, critical incidents and never events.

• Coordinates medical record requests, as appropriate, and reviews medical records to complete investigation.

• Works in collaboration with CMO, market medical directors and QOC Manager in the investigation of quality of care issues.

• Monitors quality of care issues and develops corrective action plans for areas of concern.

• Reviews and monitors high-risk, high-volume, and unusual events concurrently and retrospectively as they occur.

• Manages the occurrence reporting system ensuring timely and appropriate incident investigation, remediation and documentation.

• Prepares summary of findings, assigns severity levels to case, when appropriate, and prepares resolution letter to customer.

• Prepares and sends corrective action plans in collaboration with Medical Directors.

• Prepares case studies for presentation to Physician Advisory Committee (PAC).

• Assists with preparation of and may present quarterly reports to Corporate Quality Improvement Committee (CQIC) and PAC.

• Assists in the preparation, management and presentation of other Quality activities and reports including submission of all compliance related documentation.

• Maintains performance against established targets.

• Participates in inter-rater reliability testing to ensure consistency of reviews.

• Maintains knowledge of policies and procedures and assures team performs assigned duties in accordance with applicable regulatory requirements, State and accreditation standards.
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• Performs other job-related duties as required;

Core Competencies and Skill Requirements:

• Strong knowledge of common patient disease processes and usual methods of treating them;

• Thorough knowledge of medical terminology and commonly used equipment;

• Ability to effectively evaluate medical records for appropriateness of care;

• Ability to assess and judge the clinical performance of physicians and other health professionals;

• Strong analytical, assessment and problem-solving skills;

• Effective oral and written communication skills, including the ability to effectively explain complex information and document according to standards;

• Intermediate skills in Word, PowerPoint, Excel, and Outlook with basic ability to enter data into and navigate through a database;

• Maintains confidentiality of all sensitive documents, records, discussions and other information generated in connection with quality of care activities;

• Self-directed and able to work independently. Uses appropriate judgment to seek assistance and ask questions ;

• Keeps QOC Manager updated on overall activities, issues identified, and actions to address issues;

• Strong attention to detail and work accuracy;

Required/Preferred Education, Experience, and Training:

• Current, active and unrestricted Registered Nurse (RN) license;
• Three to five years of quality review and improvement experience preferred
• Experience with CMS, NCQA standards, HEDIS, CAHPS, HOS and quality management preferred.
• Knowledge/experience in the Medicare/Medicaid industry preferred.
• Strong project management, research and analytical skills preferred.

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 annual salary of 73,200 - 122,000 USD / yearly, depending on relevant factors, including experience and geographic location.

This role is also anticipated to be eligible to participate in an annual bonus plan.

We want you to be healthy, balanced, and feel secure. That’s why 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) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at Cigna Group.

About The Cigna Group

Doing something meaningful starts with a simple decision, a commitment to changing lives. At The Cigna Group, we’re dedicated to improving the health and vitality of those we serve. Through our divisions Cigna Healthcare and Evernorth Health Services, we are committed to enhancing the lives of our clients, customers and patients. 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.

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.

The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.

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