RN Utilization Review Nurse (In-Office)Houston,Texas
 Houston, TX

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The Nurse is responsible for supporting the Medical Director and Director of Pre-Certification. Responsibilities include assuring health care services are available to Cigna HealthSpring members in an appropriate cost-effective manner and delivery of those services to promote healthy outcomes.

Essential Duties and Responsibilities:

  • Responsibilities include collecting, analyzing, and evaluating clinical documentation received using established criteria to determine appropriateness of clinical decisions; Meet/exceed service level goals (e.g., Grade of Service, Average Handle Time, Average Speed to Answer, Abandonment Rate);
  • Adherence to regulatory and departmental timeframes for review of requests received;
  • Collaborates with the Medical Director to identify utilization trends and generation of monthly written reports;
  • Process approval and adverse clinical determination correspondence for members related to Prospective request for services.
  • Initiate the letter of agreement process, working with Network Management to ensure Service Level Agreements are completed in a timely manner when applicable;
  • Proficient knowledge of Health Services policies and procedures, Medicare, HIPPA and NCQA standards;
  • Professional demeanor and the ability to work effectively within a team or independently;
  • Flexible with the ability to shift priorities when required;
  • Coordinates with member, family, and caregivers to help resolve barriers to care;
  • Successfully collaborates with member and family to assure comprehension of available resources;
  • Other duties as required


  • Registered Nurse with 1-3yrs experience in a Managed Care environment.
  • Valid Nursing License in the Cigna HealthSpring's member areas or ability to obtain in a reasonable time period as established by the Director of Health Services or Medical Director.
  • Working knowledge of medical coding (CPT/ICD-9) and medical necessity criteria (e.g., InterQual, Highmark, Trail Blazer)

Knowledge, Skills, Abilities Required:

  • Excellent interpersonal and communications skills with nursing staff, physicians, nurse practitioners and other health workers involved in the care of a member
  • Ability to meet deadlines and manage multiple priorities, and effectively adapt and respond to complex, fast-paced, rapidly growing, and results-oriented environments
  • Able to work in a dynamic, fast-paced team environment and to promote team concepts
  • Excellent typing skills

Computer Skills:

Substantial knowledge of Microsoft Office including SharePoint, Outlook, PowerPoint, Excel and Word.

Qualified applicants will be considered without regard to race, color, age, disability, sex (including pregnancy), childbirth 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 an accommodation based on your physical or mental disability please email: SeeYourself@cigna.com. Do not email SeeYourself@cigna.com for an update on your application or to provide your resume as you will not receive a response.