MAJOR RESPONSIBILITIES

• Part of a clinical team that provides medical management services to customers worldwide but mainly in Africa region.
• Give evidence-based advice on pre-authorization, considering internationally accepted protocols and local and/or regional customs and regulations.
• Assessing pre-authorization requests claims in line with the policy coverage and medical necessity.
• Identify and refer cases to the Cigna Clinical team for case management, disease management and other clinical services
• Assist and support the team in cost containment, assist in projects and service delivery to meet goals.
• To assist queries from providers and payers via phone calls or e-mails
• Be fully versed with medical insurance policies for various groups / beneficiaries.
• Might be required to assist in training colleagues and sharing knowledge.
• Ability to review, investigate, and respond to external and internal inquires/complaints and provide guidance to other clinical and non-clinical staff related to medical necessity.
• Assist in fraud detection
• Meeting the defined qualitative and quantitative key performance metrics for the assigned job role.
• Ensure adherence to the predefined TATs for pre-approvals
• Achieving required targets assigned by the team leader on daily, weekly, and monthly basis.
• Ensure compliance to any changes in terms of system parameters or process.
• Other duties as assigned

REQUIREMENTS

• University degree of Medical /Nursing specialization with international healthcare experience.
• 2-3 years of clinical experience preferable in a payer setting on medical management.
• Experience in the Africa region & International market
• Fluent in English along with either French, Portuguese or Spanish, any other language is a plus
• Strong interpersonal and communication skills.
• Must be a computer literate
• Knowledge of utilization, cost containment services, insurance coverage.
• Ability to build solid working relationships with staff, clients, customers, and healthcare providers.
• Demonstrates pro-active problem-solving and analytical skills
• Ability to work under pressure and meet tight deadlines
• Flexible to work on shifts/varying work schedules.

MAJOR RESPONSIBILITIES

• Manages an active caseload of case management cases for Cigna and provides one on one case management to customers to improve health status, reduce health risks and improve quality of life.
• Uses clinical knowledge and Cigna approved guidelines and tools to assess diagnosis and treatment plans and goals and identifies gaps in care or risks for readmission or complications.
• Works with a multicultural population and is constantly aware of the cultural differences among that population.
• Establishes patient centric goals and interventions to meet the member’s needs
• Interfaces with the member, family members/caregivers, and the healthcare team, as well as internal matrix partners.
• Delivers clinical programs including case management, chronic condition management, hospital support program, etc.
• Balances business needs with patient advocacy
• Assesses member’s health status and treatment plan and identifies any gaps or barriers to healthcare.
• Visit providers to manage and coordinate care for customers by reviewing medical and claim information, ensure compliance with approved services and fees and discuss cases with hospital staff and physicians.
• Establishes a documented patient centric case management plan involving all appropriate parties (client, physician, providers, employers, etc), identifies anticipated case results/outcomes, criteria for case closure, and promotes communication within all parties involved.
• Work with Cigna physicians to evaluate complex cases and receive appropriate clinical expertise on diagnosis and treatment plans
• Responsible for delivering to customers clinical programs including case management, chronic condition management, lifestyle coaching, pre assignment assessment and any other program delivered by global clinical operations.
• Coordinate care with other nurses from other regions around the world when a need for local or regional expertise is important for better care or to comply with regulations
• Maintains accurate workflow and process documents
• Adheres to professional practice within scope of licensure and certification quality assurance standards and all case management policy and procedures
• Participates in unit and corporate training initiatives and demonstrates evidence of continuing education to maintain clinical expertise and certification as appropriate.
• Demonstrates sensitivity to culturally diverse situations, clients and customers.
• Serve as clinical liaison to Clients
• Other duties as assigned

REQUIREMENTS

• Bachelor’s in nursing, 3-5 years of experience in international clinical management
• Experience in the Africa region & International market
• Fluent in English along with either French, Portuguese or Spanish, any other language is a plus
• Demonstrated organizational and leadership skills
• Strong interpersonal and communication skills
• Demonstrates problem-solving and analytical skills.
• Ability to act as an “advocate” for the customer while complying with internal policies and procedures and contractual/legal compliance requirements
• Ability to operate personal computer, proficient with Microsoft office products, call center software, and a variety of software.
• Experience with clinical guidelines solutions such as coverage policy and MCG guidelines
• Ability to build solid working relationships with staff, matrix partners, customers and providers
• Flexible to work on shifts/varying work schedules.

MAJOR RESPONSIBILITIES

• Part of a clinical team that provides medical management services to customers worldwide but mainly in Africa region.
• Give evidence-based advice on pre-authorization, considering internationally accepted protocols and local and/or regional customs and regulations.
• Assessing pre-authorization requests claims in line with the policy coverage and medical necessity.
• Identify and refer cases to the Cigna Clinical team for case management, disease management and other clinical services
• Assist and support the team in cost containment, assist in projects and service delivery to meet goals.
• To assist queries from providers and payers via phone calls or e-mails
• Be fully versed with medical insurance policies for various groups / beneficiaries.
• Might be required to assist in training colleagues and sharing knowledge.
• Ability to review, investigate, and respond to external and internal inquires/complaints and provide guidance to other clinical and non-clinical staff related to medical necessity.
• Assist in fraud detection
• Meeting the defined qualitative and quantitative key performance metrics for the assigned job role.
• Ensure adherence to the predefined TATs for pre-approvals Achieving required targets assigned by the team leader on daily, weekly, and monthly basis.
• Ensure compliance to any changes in terms of system parameters or process. Other duties as assigned 

REQUIREMENTS

• University degree of Medical /Nursing specialization with international healthcare experience. 2-3 years of clinical experience preferable in a payer setting on medical management.
• Experience in the Africa region & International market
• Fluent in English along with either French, Portuguese or Spanish, any other language is a plus
• Strong interpersonal and communication skills. Must be a computer literate
• Knowledge of utilization, cost containment services, insurance coverage.
• Ability to build solid working relationships with staff, clients, customers, and healthcare providers.
• Demonstrates pro-active problem-solving and analytical skills Ability to work under pressure and meet tight deadlines
• Flexible to work on shifts/varying work schedules. 

MAJOR RESPONSIBILITIES

• You are responsible for clinical case management and cost containment in relation to international hospitalizations and claims, and you assist in drafting Guarantees of Payment.
• You screen hospital bills before they are approved for reimbursement & direct billing
• You coordinate and manage all aspects of treatment including medical appropriateness, length of stay in an efficient and cost-effective manner.
• You are in contact with the treating doctors or facilities to obtain necessary medical information and to negotiate tariffs.
• You identify and refer appropriate customers to eligible clinical programs.
• You maintain timely and efficient documentation.
• You liaise with patient or family members about treatment changes or patient care
• You consult the client organizations and account managers whenever necessary
• You take into consideration the necessary procedures and agreements
• Other duties as assigned

REQUIREMENTS

• You have a bachelor or master’s degree preferably in a medical orientation or equal through experience.
• You have past experience in the Medical Insurance. Past expeirence in Hospital & Clinics or any Clinical background is an asset.
• Experience in the Africa region & International market
• You are fluent in English and have good knowledge in French and/or Portuguese and/or Spanish, any additional language is an asset but not essential.
• You have a thorough medical knowledge and a genuine interest in the evolutions in the medical world.
• You are strong in assimilating different information and negotiating and you are critical and communicative.
• You are skilled in computer
• You are flexible to work in shifts
• You are service oriented, and you can display empathy.
• You are organizationally well grounded and can work independently.
• You are stress resistant and you like to work in a team.
• You can work discretely with confidential information.