Registered Nurse, Clinical Waste & Abuse Reviewer - Cigna Healthcare - Remote

📋 Description

• • As a Registered Nurse, Clinical Waste & Abuse Reviewer at The Cigna Group, you will be at the forefront of ensuring healthcare quality and affordability by meticulously examining medical records, claims, and documentation. Your core mission will be to apply your extensive clinical judgment and analytical prowess to identify and mitigate instances of healthcare waste and abuse, thereby protecting both members and providers.
• • This pivotal role involves a deep dive into clinical data to determine medical necessity, validate coding accuracy, and ensure strict adherence to coverage policies. You will be instrumental in uncovering potential trends in waste and abuse, translating these complex insights into actionable strategies for payment integrity improvements.
• • Collaboration is key in this position. You will work hand-in-hand with Medical Directors, the Complex Claim Unit, and various matrix partners, providing essential clinical expertise to support sound, defensible, and ethical clinical decisions that uphold the integrity of the healthcare system.
• • Your responsibilities will encompass conducting both targeted and exploratory reviews across a diverse range of products and benefit plans. The primary objective of these reviews is to enhance pre-payment accuracy, preventing potential overpayments and ensuring that services rendered are appropriate and necessary.
• • You will serve as a vital clinical resource for internal teams, offering clear explanations and guidance on clinical editing programs and the outcomes of review processes. Your ability to translate complex clinical information into understandable terms will be crucial for fostering a shared understanding and promoting best practices.
• • Analyzing intricate clinical information will be a regular part of your duties. You will be expected to efficiently and professionally escalate high-risk or sensitive cases that require further attention or specialized intervention, ensuring that critical issues are addressed promptly.
• • A significant aspect of the role involves referring appropriate cases for potential fraud investigation. By meticulously identifying and flagging suspicious activities, you will contribute to maintaining a robust and ethical integrity framework within the organization.
• • Effective communication is paramount. You will engage in clear, respectful, and professional dialogue with providers, internal stakeholders, and leadership. This communication will be focused on supporting shared goals, resolving discrepancies, and fostering positive working relationships.
• • Your contributions will extend to driving continuous improvement initiatives. You will actively participate in special projects, contribute to the development of evolving review strategies, and identify opportunities to enhance the efficiency and effectiveness of our payment integrity processes.
• • This role demands a balance of independent decision-making and strong teamwork. You will be expected to take ownership of your work, maintain high standards of accountability, and consistently meet quality benchmarks, all while contributing positively to the collective success of the team.
• • By leveraging your clinical acumen and analytical skills, you will play a direct role in shaping a more efficient, equitable, and affordable healthcare landscape for Cigna's members and providers.