Primary Function:Coordinate and manage relationships with participating provider practices. Maintain detailed understanding of HEDIS / STAR performance measures. Develop and maintain a process to ensure all customers in participating provider practices meet all quality metrics. Responsible for coordinating the delivery of cost-effective, quality -based health care services for health plan customers by development and implementation of alternative treatment plans that address individual needs of the customer, their benefit plan, and community resources. Plans, implements, and evaluates appropriate health care services in conjunction with the physician treatment plan. Utilizes clinical skills to assess, plan, implement, coordinates, monitor and evaluates options and services in order to facilitate appropriate healthcare outcomes for customers.Responsibilities:Identifies gaps in needed quality metrics for customers and communicates to providerMaintains physical presence in participating provider practicesIdentifies 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 schedulingCollaborates with the attending physician to achieve identified patient outcomes.Attend and participate in weekly Complete Health Team roundsPerform telephonic outreach or home visits, as neededCommunicates 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.Supervisory Responsibilities:NoneQualifications:Current Licensure as a registered nurse, in the state of residency. in good standing.Associates degree, diploma or B.S. in NursingThree to Five (3-5) years recent experience in an acute-care environment, case-management or utilization management position (experience can be a combination of LVN/RN licensure)Previous HEDIS and/or CMS STARs experience a plusBilingual - preferred Spanish both conversational and writtenJob Related Skills:Verbal and written communication skillsInterpersonal skillsBasic Mathematical and statistical abilityOrganizational skillsTyping and computer knowledge- able to type 35WPMKnowledge of utilization review requirements and proceduresKnowledge of current health care practices and appropriate treatments.Knowledge of community resourcesAbility to travel to and work at participating provider officesWorks independently with minimum of supervisionIf 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.