(RN) Utilization Review Nurse - Complex Claim Unit at Cigna

Posted in General Business 13 days ago.

This job brought to you by eQuest

Type: Full-Time
Location: Memphis, Tennessee





Job Description:

Utilization Review Nurse - Complex Claim Unit-Work from Home

Provides review of high dollar claim review for outpatient and/or inpatient clinical services. Manages the provision of cost containment services by determining the medical necessity and coding and billing errors. Reviews cases for potential fraud and abuse and makes referrals.

This is a work at home role. Multiple locations

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 met.

  • Evaluate itemized bills against reimbursement policies.

  • Adheres to quality assurance standards.

  • Serves as a resource to facilitate understanding of products

  • Handles some escalated cases; secures supervisory assistance with problem solving and decision making

  • Advises supervisory staff of any concerns or complaints expressed by Health Care Professions and

  • Utilizes effective communication, courtesy and professionalism in all interactions, both internally and externally.

  • Performs additional unit duties below as appropriate:

    • Participate on special projects.

    • Perform random or focused review as required.

    • Support and assist with training and precepting as required



  • Interface with contracting and provider relations as appropriate to meet customer's needs

  • Analyze clinical information

  • Perform claim reviews with focus on coding and billing errors

  • Interact with the medical director when unable to approve a request

  • Identify and refer cases for possible fraud/abuse or questionable billing practices to the appropriate matrix partners

  • Perform random or focused review when needed

  • Handle multiple products and benefit plans

  • Works under moderate direct supervision

Minimum Requirements


  • Associate Degree or Nursing Diploma

  • Current RN licensure (unrestricted) in state of residence required

  • Maintain active nursing licensure as required by state and company guidelines

  • Clinical experience in acute/inpatient setting for 2 or more years required

  • Proficient on the computer and ability to navigate independently

  • Computer skills and typing expertise required

  • Recent Utilization Review or Claims Review experience strongly preferred

  • Utilization management experience strongly preferred

  • Excellent time management, organizational, research, analytical, customer service, communication (verbal and written) and interpersonal skills

  • Utilization Management and insurance industry experience preferred

  • Ability to function as part of a team

  • Ability to multi-task

This position is not eligible to be performed in Colorado.

About Cigna

Cigna Corporation (NYSE: CI) is a global health service company dedicated to improving the health, well-being and peace of mind of those we serve. We offer an integrated suite of health services through Cigna, Express Scripts, and our affiliates including medical, dental, behavioral health, pharmacy, vision, supplemental benefits, and other related products. Together, with our 74,000 employees worldwide, we aspire to transform health services, making them more affordable and accessible to millions. Through our unmatched expertise, bold action, fresh ideas and an unwavering commitment to patient-centered care, we are a force of health services innovation.

When you work with Cigna, you'll enjoy meaningful career experiences that enrich people's lives while working together to make the world a healthier place. What difference will you make? To see our culture in action, search #TeamCigna on Instagram.

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.





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