Major Job Responsibilities
- Responsible for leveraging clinical and/or coding experience and perform facility and provider medical record reviews in support the development of a dispute decision as it relates to Payment Integrity Program Claim disputes (i.e. Claims XTEN, Prepay Vendors, etc.).
- Utilize clinical data and/or coding guidelines, medical information, benefit plan, coverage policies, LCDs and NCDs to support defensible and accurate dispute decisions.
- Initiate referrals and interact with Medical Directors.
- Function independently in a fast paced and continuously evolving department.
- Collaborate with matrixed partners such as Physicians, Operations, Vendors, etc.
- Adheres to production and quality metric goals.
- Support for client facing teams as needed relating to client inquiries related to provider disputes.
- Communicate and partner with Operations teams regarding important issues and trends.
- Manages escalated cases expediently.
- Secures supervisory assistance with problem solving and decision making as needed.
- Utilizes effective communication, courtesy, and professionalism in all interactions, both internally and externally.
- Identify and refer cases for possible fraud to the appropriate matrix partners.
- Participates in special projects as needed.
- Performs additional duties as assigned.
Requirements
- Bachelor’s or associate Degree or Nursing Diploma.
- Current RN licensure (unrestricted) in state where reside. Must maintain active nursing license as required by state and company guidelines.
- Clinical experience in acute setting for 2 or more years.
- Experience with Medicare Advantage clinical reviews for claims, disputes or appeals.
- Experience with Diagnosis Related Grouping (DRG), LCDs and NCDs, Medically Unlikely Edits (MUE), Medical Necessity and Readmissions.
- This position requires at least one year experience in coding knowledge and industry expertise to ensure adherence to proper coding and billing guidelines [i.e. International Classification of Diseases, Ninth and Tenth Revisions, Clinical Modification and Procedure Coding System (ICD-9 and 10, CM and PCS) American Medical Association Current Procedural Terminology (CPT) Coding system, and Healthcare Common Procedure Coding System (HCPCS) codes].
Preferred Requirements
- Recent Utilization Review or Claims Review experience.
- Knowledge of the Insurance Industry.
- Knowledge of NCQA and URAC Guidelines.
- Certified Coder.
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 62,900 - 104,800 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 Group.
About The Cigna Group
Doing something meaningful starts with a simple decision, a commitment to changing lives. At The Cigna Group, we’re dedicated to improving the health and vitality of those we serve. Through our divisions Cigna Healthcare and Evernorth Health Services, we are committed to enhancing the lives of our clients, customers and patients. Join us in driving growth and improving lives.
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.
Qualified applicants with criminal histories will be considered for employment in a manner
consistent with all federal, state and local ordinances.
The Cigna Group 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.
