CignaNURSE CASE MANAGER SPECIALIST (TEAM LEAD)
May. 2018 - Feb. 2023Conducted detailed assessments of patient needs, medical histories, and treatment options to create personalized care plans that align with company policies and healthcare regulations. Provided ongoing support to patients and families, offering education, counseling, and guidance on navigating healthcare systems, insurance coverage, and available resources. Monitored treatment progress by maintaining regular contact with patients, adjusting care plans as necessary based on medical updates, patient needs, and physician recommendations. Developed utilization reviews to evaluate the appropriateness of care and services, ensuring that claims met medical necessity criteria, contributing to cost-saving initiatives. Ensured compliance with state and federal regulations, insurance guidelines, and healthcare protocols to minimize risks and enhance service quality. Utilized data-driven decision-making, leveraging company software and analytics to track outcomes, identify trends, and drive continuous improvement in case management processes. Collaborated with claims adjusters to address discrepancies, provide medical insights, and support accurate claims determinations, improving customer satisfaction and resolution times. Maintained up-to-date knowledge of emerging healthcare trends, insurance policies, and regulations, allowing for efficient case management and advocacy for patient care within the insurance framework.