Utilization Review Nurse

2 days ago


West Bloomfield Township, Michigan, United States The Cigna Group Full time
About the Role

We are seeking a highly skilled Utilization Review Nurse to join our team at The Cigna Group. As a key member of our Appeals and Case Management team, you will play a critical role in ensuring that our members receive the best possible care and support.

Key Responsibilities
  • Conduct thorough reviews of medical records and other documentation to determine the appropriateness of medical services and treatments.
  • Communicate with members, providers, and other stakeholders to gather information and resolve appeals and grievances.
  • Apply knowledge of Medicare and Medicaid regulations to make informed decisions and ensure compliance.
  • Collaborate with internal teams to develop and implement effective case management strategies.
  • Provide excellent customer service and ensure timely resolution of appeals and grievances.
Requirements
  • 3-5 years of experience in Medicare Advantage Health Plans or related experience in a healthcare setting.
  • Working knowledge of Medicare Advantage, Original Medicare, and Medicaid appeal regulations.
  • Excellent communication and interpersonal skills.
  • Ability to work independently and as part of a team.
  • Strong analytical and problem-solving skills.
What We Offer

We offer a comprehensive benefits package, including medical, vision, dental, and well-being and behavioral health programs. You will also have access to professional development opportunities and a competitive salary.

Join our team and contribute to the delivery of high-quality healthcare services to our members.



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