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

• MBBS .
• Maintain active Medical license as required by state and company guidelines
• Clinical experience in hospital/Medical Insurance for 2 or more years
• Team player
• Flexible/Adaptable
• Excellent time management, organizational, and research skills
• Experience with MS Office Suite (Outlook, Excel, Access, Share Point)

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.