Medical Claims Review Senior Analyst/Clinical supervisor – Complex Claim Unit

Provides clinical review expertise for high dollar and complex claims, including facility and professional bills. Provides cost containment services by identifying coding and billing errors and insuring application of Medical and Reimbursement Policies. Additionally identifies cases for potential fraud and abuse and makes referrals.

Major Job Responsibilities

Evaluates medical information against criteria, benefit plan, coverage policies and determines necessity for procedure and refers to Medical Director if criteria are not metEvaluate itemized bills against reimbursement policiesAdheres to quality assurance standardsServes as a resource to facilitate understanding of productsHandles some escalated cases; secures supervisory assistance with problem solving and decision makingAdvises supervisory staff of any concerns or complaints expressed by Health Care ProfessionalsUtilizes effective communication, courtesy and professionalism in all interactions, both internally and externallyPerforms additional unit duties below as appropriate:Participate on special projects.Perform random or focused reviews as required.Support and assist with training and precepting as requiredAnalyze clinical informationPerform claim reviews with focus on coding and billing errorsIdentify and refer cases for possible fraud/abuse or questionable billing practices to the appropriate matrix partnersHandle multiple products and benefit plansWorks under moderate direct supervision

Qualifications

MBBS or BSc/MSc Nursing.Maintain active Medical/nursing license as required by state and company guidelinesClinical experience in hospital/clinic for 2 or more yearsTeam playerFlexible/AdaptableExcellent time management, organizational, and research skillsExperience with MS Office Suite (Outlook, Excel, Access, SharePoint)

Preferred Qualifications

Utilization Review or Claim Review experience in Health insuranceKnowledge of the Principles of Health Care Reimbursement

Key Skills and Competencies

Strong background in quantitative decision making, ability to drive business/operations metricsMetrics-driven. Able to translate strategy into measurable operational goals and objectives. Disciplined in assessing performance and addressing problems.Good communication and strong interpersonal skills.Highly organized, structured & proactive.Good inter-cultural skills & Exposure to global work environment.Good time management skills - meet tight timelines and manage ad hoc deliverables, if any.

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.