Job Description

The Clinical Risk Management Specialist will support all aspects of the Clinical Quality and Clinical Risk Management Program by identifying, assessing and making recommendations to manage/ mitigate risk to advance patient safety and positively impact the patient and provider experience and satisfaction.

Responsibilities

Conduct Clinical quality Case Reviews and investigations (i.e., Clinical Case Reviews, C360 complaints, Better Business Bureau complaints etc.) and draft management reports detailing findings

Timely processing of release of information (medical records) requests inclusive of data entry (Smart Sheet), appropriate intra-department collaboration, record retrieval and the correct release of information

Contribute to the development of the annual Clinical Risk Management Plan

Conduct staff clinical risk management training as appropriate

Support Clinical Complaint service recovery process inclusive of customer outreach, resolving complex issues, etc. with an \xe2\x80\x9cElite\xe2\x80\x9d service mentality and sense of urgency in meeting service level for patient and provider satisfaction

Maintains accurate tracking and trending documentation of QM and RM tasks and activities, projects,

Monitor and support providers in understanding and achieving compliance with quality benchmarks (i.e., KPI\xe2\x80\x99s, etc.)

Provide support of the clinical policy management process

Provide support of the multiple medical group committee activities

Provide support of the chart review process to ensure compliance with clinical guidelines and policies.

Foster a clinical teamwork partnership approach with cross departmental projects and initiatives.

Other duties and projects as assigned.

Qualifications

Medical Assistant preferred

Bachelor\xe2\x80\x99s degree preferred

Risk Management certification preferred

Minimum 1 year of customer service, clinical/healthcare experience with knowledge of operational and clinical concepts, best practices, and metrics

Multi- specialty experience preferred (Behavioral Health,VPC, Derm)

Ability to work as a team player and independently to complete assignments, tasks, and projects

Excellent communication skills (written and oral) communication, problem solving, critical thinking skills and conflict resolution (i.e., de-escalate difficult situations) skills aimed at service recovery

Knowledge and skills of quality improvement methodologies

Goal-oriented with the ability to manage multiple priorities in a diverse and fast-paced environment

Strong investigative and excellent analytical, and problem-solving skills with attention to detail required as well as excellent time-management skills

Knowledge of Tableau and strong Excel and PowerPoint skills required

Exercise professionalism and flexibility with a wide degree of creativity and latitude

Must be a team player and able to work well under deadline pressure to meet timeline requirements

This role is Hybrid.

If 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 Evernorth Health Services

Evernorth Health Services, a division of The Cigna Group, creates pharmacy, care and benefit solutions to improve health and increase vitality. We relentlessly innovate to make the prediction, prevention and treatment of illness and disease more accessible to millions of people. 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: SeeYourself@cigna.com for support. Do not email SeeYourself@cigna.com 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.

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