Medical Claims Review Senior Analyst / Medical Advisor

The Medical Advisor is a member of the medical team which develops and manages health and wellness programs for Cigna customers. Together with a team of nurses and physicians she / he will ensure attainment of quality, production, timeliness, cost containment goals, and excellent customer satisfaction for both internal and external customers. Ability to review, investigate, and respond to external and internal inquires / complaints. Provides guidance and acts as a mentor or coach for the nurses and other non-clinical staff.

He / she works with a multicultural population and is constantly aware of the cultural differences among that population and the geographical regions.

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
• Analyze clinical information
• 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

Qualifications

Preferred Qualifications

Key Skills And Competencies

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.

Skills Required

Mbbs, Ms Office Suite, Outlook, utilization review , Sharepoint, Access, Excel