As a key member of the Waste & Abuse (WA) Clinical Editing Team, reviews medical records for potential waste and abuse cost containment opportunities related to medical necessity and/or coding and billing errors. Identifies potential waste and abuse trends for additional payment integrity opportunities. Partners with Complex Claim Unit on Hospital Bill Reviews.

Major Job Responsibilities

• Evaluates medical information against criteria, benefit plan, coverage policies and determines necessity for procedure.

• Perform random or focused reviews.

• Make referrals and interact with Medical Directors.

• Evaluate medical records against clinical/ reimbursement policies and specific job aides.

• Adheres to quality assurance standards.

• Serves as a resource to facilitate understanding of WA Clinical Editing Team and Complex Claim Unit Programs.

• Handles escalated cases expediently.

• Secures supervisory assistance with problem solving and decision making as needed.

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

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

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

• Analyze clinical information.

• Identify and refer cases for possible fraud to the appropriate matrix partners

• Participates in special projects as needed

• Handle multiple products and benefit plans

• Performs additional duties as assigned.

Preferred Requirements

• Recent Utilization Review or Claims Review experience

• Intermediate Computer and typing skills

• Certified Coder

• Utilization management experience

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

• Ability to function independently, but part of a team

• Ability to multi-task

• Knowledge of Utilization Management and Insurance Industry

Qualifications or Minimum Requirements

• Associate Degree or Nursing Diploma

• Current RN licensure (unrestricted)

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

• Clinical experience in acute setting for 2 or more years

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.

For this position, we anticipate offering an annual salary of 58,700 - 97,900 USD / yearly, depending on relevant factors, including experience and geographic location.

This role is also anticipated to be eligible to participate in an annual bonus plan.

We want you to be healthy, balanced, and feel secure. That's why you'll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you'll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k) with company match, company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, visit Life at Cigna .

About Cigna

Cigna Corporation exists to improve lives. We are a global health service company dedicated to improving the health, well-being and peace of mind of those we serve. Together, with colleagues around the world, 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 us, or one of our subsidiaries, you'll enjoy meaningful career experiences that enrich people's lives. What difference will you make?

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.

Cigna 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.