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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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