Medical Claims Review Analyst – 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 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 Professionals
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 reviews as required.
Support and assist with training and precepting as required
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Perform claim reviews with focus on coding and billing errors
Identify and refer cases for possible fraud/abuse or questionable billing practices to the appropriate matrix partners
Handle multiple products and benefit plans
Works under moderate direct supervision
- MBBS
Maintain active Medical as required by state and company guidelines
Clinical experience in hospital/clinic for 3 or more years
Team player
Flexible/Adaptable
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, ability to drive business/operations metrics
Metrics-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.
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