Senior Medical Claims Review Analyst/Clinical Supervisor - Complex Claim Unit

Join our team as a Senior Medical Claims Review Analyst/Clinical Supervisor and play a critical role in driving business growth and improving lives. This exciting opportunity is based in our Remote facility and offers a competitive salary and benefits package.

Job Summary

We are seeking a highly skilled and experienced Medical Claims Review Senior Analyst/Clinical Supervisor to lead our Complex Claim Unit. As a clinical expert, you will provide review expertise for high-dollar and complex claims, identify coding and billing errors, and ensure compliance with Medical and Reimbursement Policies. You will also serve as a resource to facilitate understanding of products and handle escalated cases.

Key Responsibilities

• Evaluate medical information against criteria, benefit plans, and coverage policies to determine necessity for procedures
• Review itemized bills against reimbursement policies to identify coding and billing errors
• Adhere to quality assurance standards and serve as a resource to facilitate understanding of products
• Handle escalated cases and secure supervisory assistance with problem-solving and decision-making
• Identify and refer cases for potential fraud and abuse
• Participate in special projects, random or focused reviews, and training and precepting as required

Requirements

• MBBS or BSc/MSc Nursing degree
• Active medical/nursing license as required by state and company guidelines
• 2+ years of clinical experience in a hospital/clinic setting
• Excellent time management, organizational, and research skills
• Experience with MS Office Suite (Outlook, Excel, Access, SharePoint)

Preferred Qualifications

• Utilization Review or Claim Review experience in health insurance
• Knowledge of the Principles of Health Care Reimbursement

Key Skills and Competencies

• Strong background in quantitative decision-making and ability to drive business/operations metrics
• Metrics-driven with ability to translate strategy into measurable operational goals and objectives
• Good communication and strong interpersonal skills
• Highly organized, structured, and proactive
• Good inter-cultural skills and exposure to global work environment

About The Cigna Group

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!

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