Senior Cigna Utilization Review Nurse Jobs (NOW HIRING)

Job title: RN - Utilization Review

Job location: East Elmhurst, NY 11370-1381

Shift: 8:30 AM-5:00 PM

Length: 8 weeks, Possible extension

Local Hourly pay: $60 - $63/hr

Travel Weekly Pay upto: $2874/week

Education:

Associate's Degree in Nursing from an accredited educational institute.

Required Certifications & Licensure:

New York State RN License & Primary Source Verification.

AHA BLS.

1+ year of non-acute utilization review experience

Skills:

• Strong clinical assessment, analytical, and critical thinking skills with exceptional attention to detail.
• Experience conducting medical record reviews, clinical investigations, utilization review, quality assurance, risk management, or patient advocacy activities.
• Strong knowledge of medical, nursing, behavioral health, and correctional healthcare terminology and standards of care.
• Ability to communicate effectively with interdisciplinary healthcare teams, patients, and administrative leadership.
• Demonstrated interest in correctional health, public health, healthcare quality improvement, and patient-centered care.
• Commitment to ongoing professional development, and continuous quality improvement initiatives.

Duties:

1. Review and clinically assess complaints, grievances, and requests received from internal and external stakeholders to identify key healthcare-related concerns and potential gaps in care delivery.
2. Conduct comprehensive clinical reviews of electronic health records (CHER) and other healthcare information systems to obtain relevant medical, nursing, and behavioral health information necessary for case resolution.
3. Analyze clinical findings and prepare detailed summaries addressing the medical and operational issues identified during investigations.
4. Collaborate with facility-based healthcare staff, interdisciplinary treatment teams, and administrative personnel.
5. Utilize professional nursing judgment to determine whether complaints are confirmed based on clinical documentation, patient interviews, applicable standards of care, and available evidence.
6. Prepare investigative findings, clinical recommendations, and case outcomes for review by CHS senior leadership and relevant clinical disciplines; recommend corrective or preventive actions when appropriate.
7. Participate in interdisciplinary case conferences with medicine, nursing, mental health, pharmacy and clinic administration leadership to review complex patient care concerns and system issues.
8. Provide clinically informed recommendations to improve patient care, patient safety, healthcare delivery, and overall patient experience.
9. Identify trends and contribute to the development of quality improvement and performance improvement initiatives aimed at enhancing clinical outcomes and reducing recurrence of patient complaints.
10. Conduct special clinical reviews, audits, and investigations related to healthcare services, patient care practices, as assigned.
11. Perform additional duties and special projects as assigned.

Benefits

Pride Global offers eligible employee’s comprehensive healthcare coverage (medical, dental, and vision plans), supplemental coverage (accident insurance, critical illness insurance, and hospital indemnity), 401(k)-retirement savings, life & disability insurance, an employee assistance program, legal support, auto, home insurance, pet insurance, and employee discounts with preferred vendors.

Equal Employment Opportunity

Pride Health is an equal opportunity employer. We do not discriminate on the basis of the race, religious creed, color, national origin, ancestry, physical disability, mental disability, reproductive health decision making, medical condition, genetic information, marital status, sex, gender, gender identity, gender expression, age, sexual orientation, veteran or military status, or any other characteristic protected by applicable federal, state, or local law.

Fair Chance Employment

Pride Health is a Fair Chance employer. We consider all qualified applicants, including those with criminal histories, in a manner consistent with applicable state and local Fair Chance laws and ordinances, including the California Fair Chance Act and all applicable local Fair Chance ordinances.

Accommodations

We are committed to providing reasonable accommodations to applicants and employees with disabilities. If you require a reasonable accommodation to participate in the application or interview process, or to perform the essential functions of this role, please contact us.