Cigna Utilization Review Remote Jobs in Spring Hill, FL

Paradigm is seeking a Clinical Navigator to serve as a central coordination and clinical oversight resource for injured workers with complex and catastrophic workers’ compensation claims. In this role, you will partner closely with case managers, clinical associates, providers, payers, vendors, key accounts, and injured workers to help remove barriers to care, support timely and medically necessary treatment, and promote positive outcomes. The Clinical Navigator plays an important role in ensuring continuity of care, evaluating treatment appropriateness, escalating delays or risks, and delivering a high-quality, customer-first experience.

The ideal candidate will have an active RN license and 3–5 years of workers’ compensation and/or catastrophic case management experience. Experience with DME, utilization review, EMRs, care management platforms, and Microsoft Office applications is strongly preferred. This role is well-suited for a forward-thinking clinical professional who is comfortable working independently, taking initiative, and partnering collaboratively to support high-quality outcomes for injured workers.

This is a fully remote position with typical business hours; however, there may be instances when work outside of standard business hours is required based on business needs.

Responsibilities:  

• Serve as the central point of coordination and clinical oversight of assigned complex and Catastrophic cases.
• Serve as the secondary level of clinical oversight and the single point of contact for Case Managers and Clinical Associates.
• Work directly with key accounts as assigned and is responsible for providing customer excellence with every interaction.
• Apply case management skills and experience with catastrophic workers’ compensation to remove barriers with a strong focus on quality outcome, compliance and efficient case progression. 
• Evaluates treatment appropriateness and utilization.
• Ensure home health & DME services are being performed as ordered, and continue to be clinically necessary, making recommendations based on Injured workers’ needs and progress.  Ensure treatment plans align with medical necessity and payer guidelines.
• Monitor IW progress and escalate delays or identified risks.
• Identify delays, risks and care gaps and escalate appropriately. 
• Conduct QA on a predetermined number of referrals to ensure alignment with Care at Home guidelines and expectations.
• Collaborate with external agencies, providers, and vendors to coordinate care, facilitate communication, and ensure timely delivery of services and resources for patients as needed.
• Facilitate and lead case conferences and virtual roundtable discussions, as needed, to coordinate care, review patient progress, address barriers to treatment, and align stakeholders on care plans and next steps.
• Demonstrate a customer-first mindset by developing a broad and deep (where appropriate) understanding of Paradigm organization, products, operations, and customers. Prioritizes collaboration to meet customer needs and expectations and takes personal accountability for service quality.
• Utilizes AI tools to support day-to-day tasks, improve efficiency, and enhance output quality. Adopts new technologies as trained and applies them in alignment with established processes and guidelines.

Qualifications:  

• RN required.
• 3-5 years Workers’ compensation and/or complex case management, required.
• Experience with catastrophic cases, strongly preferred.
• Experience with DME, strongly preferred.
• Experience with EMRs, care management platforms, and Microsoft Office applications.
• Knowledge of Utilization Review process.
• Ability to communicate effectively and professionally with both internal and external customers.
• Must have a collaborative demeanor with a high emphasis on teamwork. 
• Strong conflict resolution and problem-solving abilities.
• Strong understanding of medical terminology.
• Strong clinical assessment and critical thinking skills.
• Excellent prioritization and time-management skills.
• Strong documentation and auditing skills.
• Bilingual (English/Spanish) a plus.
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