Public Health Nurse Salary in Nashville, TN

Nurse Practitioner (NP) performs various functions, such as diagnose, treat and manage certain diseases; perform physical exams and order tests; and write prescriptions. The NP can work without doctor supervision and can be a patient's primary care provider. This position will also practice primary care and family medicine in collaboration with a faculty physician.Daily Operations:• Performs preliminary assessment of patient through observation and interview, and physical assessment; appropriately diagnose and treat identified health problems within scope of practice; identifies patient's concerns.• Communicates procedures to patient to maximize emotional and physical comfort. Communicates procedures to patient to maximize emotional and physical comfort. Evaluates findings of examinations and procedures performed; documents in patient's record• Notifies physician when finds problems or abnormalities; performs physician examinations and procedures according to guidelines; documents inpatient chart. Identifies patient/family education needs regarding health status. Completes reports and submits to supervisor as requested. Maintains strict confidentiality in matters relating to patients and clinic personnel.• Utilized appropriate channels to communicate stressful situations and problems. Maintains flexibility in relation to patient assignment and work schedule.• Demonstrates accurate knowledge of legal implications and appropriate application of clinical and administrative policies and procedures.• Demonstrates accurate knowledge and appropriate application of clinical and administrative policies and procedures.• Practices current safety knowledge, infection control and sterilization policies, and procedures.• Actively participates in Quality Assessment programs• Responds appropriately in actual or simulated emergencies and demonstrates knowledge of fire, STAT and disaster procedures.• Provides proper cleaning and care for equipment and supplies and preventive maintenance for equipment• Performs other related duties as assigned by Executive Director, Medical Director or Supervisor.Required Skills: • Demonstrates a general understanding and knowledge of primary care, family medicine, and the Elam Mental Health Center Clinic office standards, procedures, medical terminology, and medical office practices.• Demonstrates a general understanding and knowledge of front/back office standards, procedures, medical terminology, and medical office practices.• Ability to handle multiple tasks, independently, under pressure.• Core Competencies; Patient Assessment, Clinical Procedure with Scope of Service• Knowledge of examination, diagnostic, and treatment room procedures.• Knowledge of medical equipment and instruments to administer patient care.• Knowledge of OSHA, Infection Control, and safety hazards and precautions to establish a safe working environment.• Knowledge of chart documentation requirements and recording test results.• Skill in establishing and maintaining effective working relationships with patients, medical staff, and the public.• Ability to maintain quality control standards.• Ability to interpret, adapt and apply guidelines and procedures.• Ability to operate computer and printer, general office equipment, and telephone equipmentRequired Education and Experience:The educational requirements for nurse practitioners vary by state but most require a Master's or Doctoral degree or post-Master's certificate. Preferred graduate of an approved adult or family nurse practitioner program. Must be a registered nurse in the State of Tennessee and be board certified/board eligible to practice as an adult or family nurse practitioner. Eligible for a certificate of fitness to prescribe medication in the State of Tennessee, if applicable.

The Mental Health Specialist will assist Program Manager in carrying out the clinical service plan for their assigned program. This will include providing and supervising individual therapy, group therapy, family therapy, and advocacy for assigned clients. The Mental Health Specialist will ensure that clinical services are provided according to program structure and schedule.Daily Operations• Provide clinical services (such as group therapy and individual counseling) utilizing best practices utilizing an ACT model for group and individual.• In collaboration with the Program Manager, provides behavioral and therapeutic structure.• Responsible for appropriately intervening and/or reporting program violations as they occur.• Collect and report statistical data to administration as required by funding and other agencies.• Provide psycho-educational groups and family counseling when appropriate.• Maintain a functional knowledge of best practices for service delivery that are trauma-informed, client-centered, and goal-oriented such as Motivational Interviewing.• Maintain, and practice skills regarding sensitivity to the cultural and socioeconomic backgrounds of clients and others contacted in carrying out job responsibilities.• Verify clients have received new client's orientation, insuring full understanding of program rules and procedures within twenty-four (24) hours of their arrival.• Utilizing appropriate forms hardcopy or electronic, document group and individual sessions with clients.• Maintain clinical records and required paperwork in compliance with agency standards.• Attend and participate in treatment team meetings in order to give and receive client condition reports.• Attend all appropriate client care conferences and staff meetings.• Participate in funding agency training activities as required.• Perform other departmental mission related duties as assigned by supervisor.• Be courteous, tactful, and discrete in relating to the public, other staff, and clients.• Adhere to the guidelines as stated in the Meharry Medical College Policy and Procedures Manual.• Provide other services that benefit the program and/or agency as assigned by the Program Manager or Clinical Director.Required Skills• A comprehensive knowledge of homeless services• Ability to interact effectively with staff, clients, agencies, etc.• Demonstrated effective clinical skills.Required Education and Experience• M.A. or M.S. in the Social Services Field with the ability to provide clinical services to mental health or substance abuse.

TITLE: DEMENTIA PROGRAM MANAGEROverview:The Tennessee Commission on Aging and Disability ( TCAD ) is the designated State Agency on Aging and is mandated to provide leadership relative to aging issues on behalf of older persons in the state. Our mission is to bring together and leverage programs, resources, and organizations to protect and ensure the quality of life and independence of older Tennesseans and adults with disabilities.Qualifications:Education and Experience: Graduation from an accredited college or university with a bachelor's degree and experience equivalent to three years of professional experience in planning, administering, evaluating, or assessing human service, mental health, public health, or gerontological programs. OR Possession of a master's degree in Gerontology, Gerontological Services, Human Services Administration, Psychology, Public Health Administration, Sociology, or Social Work and experience equivalent to one year of professional experience in planning, administering, evaluating, or assessing human service, mental health, public health, or gerontological programs.Duties and Responsibilities:· Directly report to the TN Dementia Services Coordinator.· Act as a liaison and point of contact between internal/external customers when the Dementia Service Coordinator is not in the office.· Provide technical assistance and support to all dementia program affiliated staff and subcontractors.· Conceptualization, Planning, Developing, and overseeing programs related to dementia education within the aging network that more effectively meet the needs of the growing demand for dementia outreach and education.· Act as the main point of contact for the Alzheimer’s Disease Program Initiative (ADPI) 3-year grant received through the Administration of Community Living (ACL).· Provide direct service through trainings for community members regarding DPI and Alzheimer’s Disease and Related Dementia (ADRD).· Become a certified master trainer through the Crisis Prevention Institute (CPI) on Dementia Capable Care (DCC) and then train others throughout the aging network on DCC.· Oversee and train the Dementia Health Navigators (DHN) that will be hired as part of the ADPI grant.· Work with DHN and AAADs on making Tennessee a more dementia-friendly and capable state.· Development and distribution of information explaining what resources are available and how to utilize those resources.· Maintaining and updating the statewide dementia resource page on the TCAD website.· Provide professional development and education to stakeholders and partners.· Develop and maintain active partnerships with other State Agencies who have an interest in meeting the needs of older adults and persons with disabilities.· Other duties as assigned.Interested, pl. reach sarah at taurusbiz dot com

Provides expert content/professional leadership on complex Clinical Program Management assignments/projects. Exercises considerable creativity, foresight, and judgment in conceiving, planning, and delivering initiatives. Uses deep professional knowledge and acumen to advise functional leaders. Focuses on providing thought leadership within Clinical Program Management but works on broader projects, which require understanding of wider business. Recognized internally as a subject matter expert.Represents company externally and serves as conduit to educate and enable care coordination between stakeholders resulting in an optimal healthcare experience and customer satisfaction. Serves as clinical advisor to the sales organization, providing ongoing product and industry knowledge/education that positively influence cost, quality and customer satisfaction. Registered Nurse with a current active licensure and clinical practice experience. Skilled in working with Microsoft Office. Ie: Excel, PowerPoint, etc. Also, serves as initial contact for clients and their eligible dependents requesting services related to assigned clinical programs. Responsible for customer service and relevant standards such as telephone response time. May make referrals within stated limits. Supports and assists with training for employees. May provide guidance around procedures and workflows. Completes day-to-day tasks without immediate supervision but has ready access to advice from more experienced team members. Tasks involve a degree of forward planning and anticipation of needs/issues. Resolves non-routine issues escalated from more junior team members.Responsibilities:Day to day management of assigned clinical programsServes as SME for assigned clinical programsPoint of contact/liaison with our internal and external partners for assigned clinical programs to remediate questions and issuesWeekly report related to status of assigned clinical programsReviewing, opening and closing of referrals to clinical programs as neededMonitoring vendor mailboxResponsible for managing all reports related to assigned clinical programsManagement of internal & external referrals for assigned marketsProviding training to other internal teams about clinical programs as needed/requestedRequirements:Active RN LicenseMinimum 2 years experienceIf 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.About Cigna Healthcare Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. 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: [email protected] for support. Do not email [email protected] 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.

Description The Whole Health & Health Equity Director is responsible providing direction and oversight for the health plans efforts to improve the health and well-being of the Health Plan's membership. Location: This is a hybrid position and will require 1-2 days per week in the Nashville office. How you will make an impact: Establishing, informing, monitoring, and accomplishing the health plan's integrated whole health strategy under the direction of the State Plan President. Championing integration and articulating the goals and value of our comprehensive whole health model to leadership, associates, and key stakeholders. Employing and implementing core concepts of whole health improvement such as social determinants of health, health services research, epidemiology, and statistics to guide the health plans strategic vision. Building, preserving, and prioritizing collaborative, sustainable relationships with public health, social services, local governmental agencies, and community-based organizations. Utilizing social needs screening tools, risk modeling, and community needs assessments to leverage relevant internal and external data sources to understand the markets population served and translate data into actionable evidence to inform strategic planning, policy, and partnership. Overseeing annual program description, whole health analysis and program evaluation documents. Minimum Requirements: Requires a BA/BS in a relevant discipline, or other degrees such as, but not limited to, master's level social work, public health, health services research, health policy, epidemiology, psychology, or another relevant field, or licensure as a registered nurse. Minimum 5 years of experience in community health improvement, public health or closely related relevant field such as whole health, service coordination, ambulatory care, case, or care management and or coordinating care within multiple settings and with multiple provider types. Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact [email protected] assistance.

ApplyDescriptionSUMMARYThe Director, Quality and Standards provides direction and oversight of the organizations Quality Program and Regulatory Standards for Alive Hospice. The Director, Quality and Standards is responsible for collaboration with all agency departments to drive the organizations compliance with regulatory and accreditation standards and facilitates process improvement through appropriate data collection, analysis, sharing and application; along with leading process improvement efforts to ensure compliance with agency, local, state and national quality initiatives.For purposes of clarification, Regulatory Compliance is defined as all health care regulatory compliance including OIG, CMS, TJC, and HIPAA and other regulations that directly or indirectly impact the operations of Alive Hospice.QUALITY ESSENTIAL DUTIES AND RESPONSIBILITIESCollaborate with the VP of Operational Improvement to achieve department and organization goals and outcomesCollaborate with the Director of IT for optimization of Agency information systems to support and improve processesFacilitation of Root Cause Analysis (RCA), Failure Mode Effects Analysis (FMEA), and Performance Improvement effortsRegularly review the Quality Program and recommends appropriate revisions and modifications to the VP of Operational ImprovementData gathering to identify opportunities for performance improvementCollaboration with all stake holders to ensure reporting needs are identified and metAnalytic support for departments across the organizationCMS quality monitoring and reportingPresent periodic and annual reports on the Quality ProgramDevelop, coordinate, and/or oversee internal and external audit procedures for the purpose of monitoring and detecting performance improvement opportunitiesRecommend solutions, and follow up to ensure that the recommendations have been implemented and are effectiveService recovery monitoring and follow upCollaborate with Healthcarefirst for collection and reporting of family satisfaction surveysElectronic Medical Record (EMR) enhancement supportCollaborate with Director of IT to design and/or refine data tools and systems to streamline agency processesREGULATORY ESSENTIAL DUTIES AND RESPONSIBILITIESMonitor state, federal and JCAHO Regulatory Compliance to help the organization prevent and/or detect violation of law, regulations, policies, or the Code of Conduct.Coordinate resources to ensure the ongoing survey readiness and adherence to state, federal an accreditation standardsDevelop education programs for all employees, agents, affiliated providers, or others working with the organizationOversee follow-up and, as applicable, resolution to survey deficiencies and self-assessmentsFacilitate plan of correction activities and follow up.Develop productive and collaborative working relationships with all levels of management.Work with Department Leadership to provide adequate information to employees of to ensure that they have the requisite information and knowledge of regulatory issues and requirements to carry out their responsibilities in a lawful and ethical mannerEnsure and understand the company's commitment to comply with all laws, regulations, company policies, and ethical requirements applicable to the conduct of the businessAssess the need for additional training and education and develop appropriate regulatory compliance tools and resources.Carry out all duties and responsibilities as assigned by the Quality and Compliance Oversight Committee and/or under the Corporate Integrity Program.Perform other duties as assignedSUPERVISORY RESPONSIBILITIESDirectly supervises Infection Control Nurse. Carries out supervisory responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.LANGUAGE SKILLSAbility to read, analyze, and interpret the most complex documents. Ability to respond effectively to the most sensitive inquiries or complaints. Ability to write speeches and articles using original or innovative techniques or style. Ability to make effective and persuasive speeches and presentations on controversial or complex topics to top management, public groups, and/or boards of directors.MATHEMATICAL SKILLSAbility to apply mathematical operations to such tasks as frequency distribution, determination of test reliability and validity, analysis of variance, correlation techniques, sampling theory, and factor analysis.REASONING ABILITYAbility to apply principles of logical or scientific thinking to a wide range of intellectual and practical problems. Ability to deal with nonverbal symbolism (formulas, scientific equations, graphs, etc.,) in its most difficult phases. Ability to deal with a variety of abstract and concrete variables.OTHER QUALIFICATIONSCommunication and Relationship Skills: Exemplifies high level of written oral and listening communication skills, always respecting patient confidentiality.Agency Policy and Philosophy: Communicates and supports agency mission and values in all professional interactions.Continuing Education: Seeks to improve knowledge and skills relative to performance of job and personal growth.Quality and Performance Improvement: Participates in new and continuing programs designed to monitor and improve quality and performance relevant to the mission and philosophy of Alive Hospice, Inc.Teamwork: Functions consistently and collaboratively as an integral part of Patient Care Team and other teams (committees, etc.) bringing experience and education to contribute to optimal team functions and outcomes.Ethics: Demonstrates a high level of work, personal and professional ethics.CERTIFICATES, LICENSES, REGISTRATIONSIf required to drive to carry out the duties of this position: current drivers license and automobile insurance as required by Tennessee State Law.PHYSICAL DEMANDSThe physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.While performing the duties of this job, the employee is regularly required to sit and talk or hear. The employee frequently is required to use hands to finger, handle, or feel and reach with hands and arms. The employee is occasionally required to stand and occasionally lift and/or move up to 25 pounds. Specific vision abilities by this job include close vision, and ability to adjust focus.WORK ENVIRONMENTThe work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is occasionally exposed to use of an automobile. The noise level in the work environment is usually moderate. Work is generally performed in a general office setting.RequirementsCONTINUING EDUCATIONThe agency requires this position to complete 15 hours of continuing education per year covering topics that will contribute to improvements in carrying out the above responsibilities. Regulatory agencies may require some disciplines to have additional hours in order to be licensed or certifiedQUALIFICATIONSTo perform this job successfully, an individual must be able to perform each essential duty satisfactorily, including meeting the required competencies. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.EDUCATION and/or EXPERIENCEBachelors degree, Masters preferred; CPHQ (Certified Professional in Healthcare Quality) preferred; 3-5 years Clinical Informatics background; demonstrated professional experience working with clinical records, documentation, billing and auditing.recblid ou038qhkwbu0pccb9do9q2qm8iq2bh

Cigna Medicare Part C Appeals Reviewer: Appeals Processing AnalystWe will depend on you to communicate some of our most critical information to the correct individuals regarding Medicare appeals and related issues, implications and decisions.The Case Management Analyst reports to the Supervisor/Manager of Appeals and will coordinate and perform all appeal related duties in a Medicare Advantage Plan. These appeals will include requests for decisions regarding denials of medical services as well as Part B drugs. The Case Management Analyst will be responsible for analyzing and responding appropriately to appeals from members, member representatives and providers regarding denials for services and denials of payment via oral and written communication; researching and applying pertinent Medicare and Medicaid regulations to determine the outcome of the appeal; provide oversight and assistance to Medical Management staff with resolution of appeal by interpreting Medicare and Medicaid regulations; reviewing documentation to ensure that all aspects of the appeal have been addressed properly and accurately; e) prepare case files for submission to Independent Review Entity, which also include writing required case summary on behalf of the plan to support appeal resolution.This position is full-time (40 hours/week) with the scheduled core business hours generally 7:00 am - 6:00 pm CST - Thursday through Sunday with occasional holiday coverage. The position requires 4 ten hour shifts per week. Job Requirements include, but not limited to: Must have experience in Medicare Appeals, Utilization Case Management or Compliance in Medicare Part CAbility to differentiate different types of requests Appeals, Grievances, coverage determination and Organization Determinations in order to ensure the correct processing of the appeal.Excellent prioritization and organizational skills; effectively manage competing priorities and multiple deadlines.Review, research and understand how request for plan services and claims submitted by consumers (members) and physicians/providers was processed and determine why it was deniedIdentify and obtain all additional information (relevant medical records, contract language and process/procedures) needed to make an appropriate determination of the appeal.Make an appropriate administrative determinations as to whether a claim should be approved or denied based on the available information and as well as research and provide a written detailed clinical summary for the Plan Medical Director. Determine whether additional pre service, appeal or grievance reviews are required and/or whether additional appeal rights are applicable and then if necessary, route to the proper area/department for their review and decision/responseComplete necessary documentation of final documentation of final determination of the appeals using the appropriate system applications, templates, communication process, etc.Communicate appeal information to members or providers with the required timeframes well as to all appropriate internal or external parties (regulatory agencies, plan administrators, etc.)Meet the performance goals established for the position in the areas of: efficiency, accuracy, quality, member satisfaction and attendanceAdhere to department workflows, desktop procedures, and policies.Work with all matrix partners to ensure accurate and timely processing of Medicare Appeals.Read Medicare guidance documents report and summarize required changes to all levels department management and staff.Support the implementation of new process as needed.Based on case work and departmental reporting, ability to identify and report trends and/or areas of opportunities to department management and peers. .Understand and investigate billing issues, claims and other plan benefit information. .Assist with monitoring, inquiries, and audit activities as needed.Additional duties as assigned.QualificationsEducation: Licensed Practical Nurse (LPN) or Registered Nurse (RN)3-5 years' experience in Medicare Advantage Health Plans or related experience in a healthcare setting handling complex inquiries and requests for serviceWorking knowledge of Medicare Advantage, Original Medicare and or Medicaid appeal regulations. Understanding of Local Coverage Determinations, National Coverage Determinations, Medicare claim process and plan rules along with working with of ICD9, ICD10Superb written and oral communication skills with particular emphasis on verbally presenting case summary and decisions.Must have the ability to work objectively and provide fact based answers with clear and concise documentation.Proficient in Microsoft Office products (Access, Excel, Power Point, Word).Prioritizes workflow on a consistent basis, applies key HIPAA and CMS guidelines in daily workflow, and meets turnaround times for assigned cases.Ability to multi-task and meet multiple competing deadlines.Ability to work independently and under pressure.Attention to detail and critical thinking skills..Learning and Applying QuicklyA relentless and versatile learnerOpen to changeAnalyzes both successes and failures for clues to improvementExperiments and will try anything to find solutionsEnjoys the challenge of unfamiliar tasksQuickly grasps the essence and the underlying structure of anythingWritten CommunicationsIs able to write clearly and succinctly in a variety of communication settings and stylesCan get messages across that have the desired effectFunctional/Technical SkillsClinical and Non Clinical functional or technical proficiencyAppropriate judgment and decision making becauseKnowledge of applicable policy and business requirementsComputer skills and ability to work in various system applications.Detail oriented and Has the functional and technical knowledge and skills to do the job at a high level of accomplishmentTime ManagementSpends his/her time on what's importantQuickly zeros in on the critical few and puts the trivial many asideCan quickly sense what will help or hinder accomplishing a goalEliminates roadblocksUses his/her time effectively and efficientlyConcentrates his/her efforts on the more important prioritiesGets more done in less time than othersCan attend to a broader range of activitiesProblem SolvingUses rigorous logic and methods to solve difficult problems with effective solutionsProbes all fruitful sources for answersCan see hidden problemsLooks beyond the obvious and doesn't stop at the first answersIs excellent at honest analysisIf 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.About Cigna Healthcare Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. 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: [email protected] for support. Do not email [email protected] 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.

Cigna Medicare Part C Appeals Reviewer: Appeals Processing AnalystWe will depend on you to communicate some of our most critical information to the correct individuals regarding Medicare appeals and related issues, implications and decisions.The Appeals Processing Analyst reports to the Supervisor/Manager of Appeals and will coordinate and perform all appeal related duties in a Medicare Advantage Plan. These appeals will include requests for decisions regarding denials of medical services as well as Part B drugs. The Case Management Analyst will be responsible for analyzing and responding appropriately to appeals from members, member representatives and providers regarding denials for services and denials of payment via oral and written communication; researching and applying pertinent Medicare and Medicaid regulations to determine the outcome of the appeal; provide oversight and assistance to Medical Management staff with resolution of appeal by interpreting Medicare and Medicaid regulations; reviewing documentation to ensure that all aspects of the appeal have been addressed properly and accurately; e) prepare case files for submission to Independent Review Entity, which also include writing required case summary on behalf of the plan to support appeal resolution.This position is full-time (40 hours/week) with the scheduled core business hours generally 8:00 am - 5:00 pm CST - Monday through Friday with occasional weekend and holiday coverage. The position requires 5 eight hour shifts per week. Job Requirements include, but not limited to: Must have experience in Medicare Appeals, Utilization Case Management or Compliance in Medicare Part CAbility to differentiate different types of requests Appeals, Grievances, coverage determination and Organization Determinations in order to ensure the correct processing of the appeal.Excellent prioritization and organizational skills; effectively manage competing priorities and multiple deadlines.Review, research and understand how request for plan services and claims submitted by consumers (members) and physicians/providers was processed and determine why it was deniedIdentify and obtain all additional information (relevant medical records, contract language and process/procedures) needed to make an appropriate determination of the appeal.Make an appropriate administrative determinations as to whether a claim should be approved or denied based on the available information and as well as research and provide a written detailed clinical summary for the Plan Medical Director. Determine whether additional pre service, appeal or grievance reviews are required and/or whether additional appeal rights are applicable and then if necessary, route to the proper area/department for their review and decision/responseComplete necessary documentation of final documentation of final determination of the appeals using the appropriate system applications, templates, communication process, etc.Communicate appeal information to members or providers with the required timeframes well as to all appropriate internal or external parties (regulatory agencies, plan administrators, etc.)Meet the performance goals established for the position in the areas of: efficiency, accuracy, quality, member satisfaction and attendanceAdhere to department workflows, desktop procedures, and policies.Work with all matrix partners to ensure accurate and timely processing of Medicare Appeals.Read Medicare guidance documents report and summarize required changes to all levels department management and staff.Support the implementation of new process as needed.Based on case work and departmental reporting, ability to identify and report trends and/or areas of opportunities to department management and peers. .Understand and investigate billing issues, claims and other plan benefit information. .Assist with monitoring, inquiries, and audit activities as needed.Additional duties as assigned.QualificationsEducation: Licensed Practical Nurse (LPN) or Registered Nurse (RN)3-5 years' experience in Medicare Advantage Health Plans or related experience in a healthcare setting handling complex inquiries and requests for serviceWorking knowledge of Medicare Advantage, Original Medicare and or Medicaid appeal regulations. Understanding of Local Coverage Determinations, National Coverage Determinations, Medicare claim process and plan rules along with working with of ICD9, ICD10Superb written and oral communication skills with particular emphasis on verbally presenting case summary and decisions.Must have the ability to work objectively and provide fact based answers with clear and concise documentation.Proficient in Microsoft Office products (Access, Excel, Power Point, Word).Prioritizes workflow on a consistent basis, applies key HIPAA and CMS guidelines in daily workflow, and meets turnaround times for assigned cases.Ability to multi-task and meet multiple competing deadlines.Ability to work independently and under pressure.Attention to detail and critical thinking skills..Learning and Applying QuicklyA relentless and versatile learnerOpen to changeAnalyzes both successes and failures for clues to improvementExperiments and will try anything to find solutionsEnjoys the challenge of unfamiliar tasksQuickly grasps the essence and the underlying structure of anythingWritten CommunicationsIs able to write clearly and succinctly in a variety of communication settings and stylesCan get messages across that have the desired effectFunctional/Technical SkillsClinical and Non Clinical functional or technical proficiencyAppropriate judgment and decision making becauseKnowledge of applicable policy and business requirementsComputer skills and ability to work in various system applications.Detail oriented and Has the functional and technical knowledge and skills to do the job at a high level of accomplishmentTime ManagementSpends his/her time on what's importantQuickly zeros in on the critical few and puts the trivial many asideCan quickly sense what will help or hinder accomplishing a goalEliminates roadblocksUses his/her time effectively and efficientlyConcentrates his/her efforts on the more important prioritiesGets more done in less time than othersCan attend to a broader range of activitiesProblem SolvingUses rigorous logic and methods to solve difficult problems with effective solutionsProbes all fruitful sources for answersCan see hidden problemsLooks beyond the obvious and doesn't stop at the first answersIs excellent at honest analysisIf 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.About Cigna Healthcare Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. 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: [email protected] for support. Do not email [email protected] 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.

Job Requirements include, but not limited to: Must have experience in Medicare Appeals, Utilization Case Management or Compliance in Medicare Part CAbility to differentiate different types of requests Appeals, Grievances, coverage determination and Organization Determinations in order to ensure the correct processing of the appeal.Excellent prioritization and organizational skills; effectively manage competing priorities and multiple deadlines.Review, research and understand how request for plan services and claims submitted by consumers (members) and physicians/providers was processed and determine why it was deniedIdentify and obtain all additional information (relevant medical records, contract language and process/procedures) needed to make an appropriate determination of the appeal.Make an appropriate administrative determinations as to whether a claim should be approved or denied based on the available information and as well as research and provide a written detailed clinical summary for the Plan Medical Director. Determine whether additional pre service, appeal or grievance reviews are required and/or whether additional appeal rights are applicable and then if necessary, route to the proper area/department for their review and decision/responseComplete necessary documentation of final documentation of final determination of the appeals using the appropriate system applications, templates, communication process, etc.Communicate appeal information to members or providers with the required timeframes well as to all appropriate internal or external parties (regulatory agencies, plan administrators, etc.)Meet the performance goals established for the position in the areas of: efficiency, accuracy, quality, member satisfaction and attendanceAdhere to department workflows, desktop procedures, and policies.Work with all matrix partners to ensure accurate and timely processing of Medicare Appeals.Read Medicare guidance documents report and summarize required changes to all levels department management and staff.Support the implementation of new process as needed.Based on case work and departmental reporting, ability to identify and report trends and/or areas of opportunities to department management and peers. .Understand and investigate billing issues, claims and other plan benefit information. .Assist with monitoring, inquiries, and audit activities as needed.Additional duties as assigned.QualificationsEducation: Licensed Practical Nurse (LPN) or Registered Nurse (RN)3-5 years' experience in Medicare Advantage Health Plans or related experience in a healthcare setting handling complex inquiries and requests for serviceWorking knowledge of Medicare Advantage, Original Medicare and or Medicaid appeal regulations. Understanding of Local Coverage Determinations, National Coverage Determinations, Medicare claim process and plan rules along with working with of ICD9, ICD10Superb written and oral communication skills with particular emphasis on verbally presenting case summary and decisions.Must have the ability to work objectively and provide fact based answers with clear and concise documentation.Proficient in Microsoft Office products (Access, Excel, Power Point, Word).Prioritizes workflow on a consistent basis, applies key HIPAA and CMS guidelines in daily workflow, and meets turnaround times for assigned cases.Ability to multi-task and meet multiple competing deadlines.Ability to work independently and under pressure.Attention to detail and critical thinking skills..Learning and Applying QuicklyA relentless and versatile learnerOpen to changeAnalyzes both successes and failures for clues to improvementExperiments and will try anything to find solutionsEnjoys the challenge of unfamiliar tasksQuickly grasps the essence and the underlying structure of anythingWritten CommunicationsIs able to write clearly and succinctly in a variety of communication settings and stylesCan get messages across that have the desired effectFunctional/Technical SkillsClinical and Non Clinical functional or technical proficiencyAppropriate judgment and decision making becauseKnowledge of applicable policy and business requirementsComputer skills and ability to work in various system applications.Detail oriented and Has the functional and technical knowledge and skills to do the job at a high level of accomplishmentTime ManagementSpends his/her time on what's importantQuickly zeros in on the critical few and puts the trivial many asideCan quickly sense what will help or hinder accomplishing a goalEliminates roadblocksUses his/her time effectively and efficientlyConcentrates his/her efforts on the more important prioritiesGets more done in less time than othersCan attend to a broader range of activitiesProblem SolvingUses rigorous logic and methods to solve difficult problems with effective solutionsProbes all fruitful sources for answersCan see hidden problemsLooks beyond the obvious and doesn't stop at the first answersIs excellent at honest analysisIf 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.About Cigna Healthcare Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. 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: [email protected] for support. Do not email [email protected] 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.