Job Description
This is a hybrid position (3 days per week in-office + 2 days work at home). The incumbent candidate can be based out of any US Cigna Healthcare office. This position is a Hybrid role which requires office alignment but is not restricted to locations that are identified in this posting. The Pharmacy Utilization Management Sr. Advisor will report to the Cigna Pharmacy Business Utilization Management team and will play a critical role in capturing, consolidating, tracking, and managing complex requirements necessary for operationalizing various components of Utilization Management clinical policy, business strategy and compliance needs into criteria build requirements.
RESPONSIBILITIES :
- Strategically analyze and document requirements for appropriateness and completeness.
- Serve as a Subject Matter Expert (SME) on UM systems and provide feedback to leadership for opportunities.
- Collect and reference compliance materials to identify additional requirements for all commercial lines of business.
- Drive communication in a highly matrixed environment across multiple organizations with exposure to senior leadership.
- Aligned to interpret the most clinically complex, highest value, and operationally difficult scenarios of clinical policies in partnership with clinicians and business requirements to define holistic requirements for the criteria build team.
- Maintain alignment of criteria manual for operational users in alignment with business requirements.
- Holistic view of UM requirements including operational cost impact, total experience including rejection logic, if RXCC is invoked, initiation of prior authorization all the way to how patient and prescriber communications are impacted.
- Maintain complex crosswalk of policy to business requirements to criteria build.
- Expected to act as SME for this role in architecting and documenting new business processes
- Other tasks as assigned.
REQUIRED EXPERIENCE/SKILLS :
- Bachelor's degree required, Master's degree preferred
- Minimum of 5 years of experience in healthcare utilization management or a related field.
- Excellent strategic thinking and problem-solving abilities.
- Process optimization and efficiency improvement
- Strong communication and organizational skills.
- Strong analytical and decision-making skills
- Experience with OnePA, CSP, ATK, and understanding of pharmacy and medical drug claim processing.
- Comfort with complex systems and processes.
- Proficiency in Microsoft Office, including Excel and Access.
- Strong organizational skills and ability to manage multiple projects.
- Ability to work independently and adapt quickly to changing environments.
- Passion for working with complex data sets and regulatory compliance
- Strong analytical skills and attention to detail
- Ability to travel as needed up to 10%
If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.
About Cigna Healthcare Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. Join us in driving growth and improving lives.
Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) 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 reasonable accommodation in completing the online application process, please email: SeeYourself@cigna.com for support. Do not email SeeYourself@cigna.com for an update on your application or to provide your resume as you will not receive a response.
The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.
Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.
Job Tags
Permanent employment, Local area, Work from home, 3 days per week,