Medical Claims Review Analyst

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

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

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.