Cigna Medicare Clinical Operations Quality Review and Audit Lead Analyst

SUMMARY

The Quality Review and Audit Analyst is responsible for Utilization Management and or Case Management monitoring to ensure compliance and accuracy. Review, analyze, and report UM quality data to support Universe Accuracy and Quality Review. Quality Review and Audit Senior Representative assists in reporting outcomes and issues to Management team.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Review of Universe to ensure compliance.
• Perform timely and accurately reviews as assigned.
• Meet production demands and maintain a high level of quality.
• Assist in identifying error trends and root causes.
• Respond to review inquiries.
• Understand the overall business model of Utilization Management.
• Ensure compliance with regulatory requirements and daily operational processes.
• Have a working knowledge of data management tools and provide oversight and monitor reporting requirements for assessment and compliance.
• Maintain departmental documentation detailing current processes and supporting documentation.
• Ensure the most up-to-date CMS guidance and regulations are utilized in audit reviews.
• Review and support Policies and Procedures incorporating current CMS guidance and regulations.
• Support projects including implementation of new processes and new CMS guidance and regulations.

QUALIFICATIONS

RN Registered Nurse Preferred

Must be dependable, self-directed, organized, detail-oriented, flexible and a team player and possess the ability to make decisions. Should be a friendly, enthusiastic, and professional person who is capable of working independently. Strong results in orientation and ability to prioritize and manage workload.

EDUCATION and/or EXPERIENCE

• Utilization Management, SNP Case Management experience required.
• Health insurance/Medicare experience required.
• Ability to identify Utilization Management CMS guidelines/regulations non-compliance.

SKILLS

The position requires software skills which include Microsoft Office (primarily Word, Excel, PowerPoint, and Outlook) and other third party reporting tools and software applicable to the insurance/managed care industry.

LANGUAGE SKILLS

Ability to write routine reports and correspondence.

MATHEMATICAL SKILLS

Ability to calculate figures and amounts.

REASONING ABILITY

Ability to apply common sense understanding to carry out detailed written or oral instructions.

ABILITIES

The position requires the ability to research, analyze, interpret trend, and act as an integral team member to implement process improvement initiatives, ability to work effectively with all levels within the organization, ability to interpret CMS guidelines and regulations, ability to adapt to changes, must have ability to multi-task, plan, prioritize and complete tasks under significant time constraints and frequent interruptions. Self-motivated, independent problem solver.

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 65,600 - 109,400 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 Cigna Healthcare

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