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Care Review Clinician

The incumbent will be active in ensuring that medical decisions made will adhere to Cigna’s guidelines.

He/she will perform pre-authorization services to ensure cost-effectiveness and appropriateness of treatment.

This will enable Cigna HK to enhance its competitive position as a health and wellness provider as well as support our bottom line through improved claims outcomes.

Case management involves pre-authorization, treatment monitoring and outcome assessment to achieve personal and company’s objective.  He/she will also provide service to internal and external customers responding to and resolving requests and queries via various communication channels – call, email and efax, etc.
Job Responsibilities:

* Liaise and coordinate with medical professionals, administrators of healthcare providers and customers to ensure the cost-effectiveness and appropriateness of the treatment;

* Obtain authorization on all necessary visits and/or surgical procedures prior to the surgery and/or procedure;

* Interface with physicians and medical staff to ensure all necessary documentation is valid and complete in a timely manner in order to obtain authorizations;

* Provide advice and guidance to our claims team in the process of adjudicating claims;

* Manage and track the performance of implemented programs;

* Keep abreast of current wellness and wellbeing initiatives and develop a network of resources;

* Explore ideas and opportunities to personalize the program to increase participation;

* Conduct Medical pre-authorization in compliance with Cigna guidelines and to assess treatment plans following standard clinical protocols and evidence-based case guidelines;

* Processes requests within required timelines;

* Requests additional information from members or providers in consistent and efficient manner;

* Special projects as assigned.

* Qualified Registered Nurse with 4 years or more clinical experience;

* Hold a valid practicing certificate and professional indemnity insurance;

* Strong research and medical knowledge (diagnosis, procedure) and previous case management experience would be a definite advantage;

* Solid experience in a call centre environment is highly preferred;

* Strong conceptual, strategic, visionary and critical thinking skills;

* The ability to work with employees at all levels;

* Strong interpersonal communication and customer service skills with the ability to motivate others;

* The ability to work both independently and as a part of a team with enthusiasm, initiative and creativity;

* Excellent skills in all Microsoft Office Programs including Word, PowerPoint, Publisher and Excel;

* Excellent communication skills in both written and spoken English and Chinese

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