Clinical Waste & Abuse Nurse Lead

Clinical Waste & Abuse Nurse Lead - Evernorth

As a Clinical Waste & Abuse Nurse Lead, you bring clinical expertise and thoughtful judgment to help protect patients, strengthen payment integrity, and support high-quality care. You play a critical role in identifying waste and abuse trends while coaching others and shaping smarter, more effective review practices. We are an ambitious, compassionate team committed to doing what’s right—for members, providers, and one another.

Responsibilities

• Lead complex clinical reviews that assess medical necessity, coding accuracy, and billing integrity to drive appropriate claim outcomes

• Identify patterns, trends, and opportunities that strengthen cost containment and payment integrity initiatives

• Serve as a trusted escalation partner for complex or non-routine cases, guiding resolution through sound clinical judgment

• Coach, train, and mentor peers and new hires, helping build confidence, consistency, and clinical excellence

• Partner with Medical Directors and cross-functional teams to advance high-quality, clinically sound decisions

• Contribute to the development of tools, job aids, workflows, and documentation that improve efficiency and clarity

• Lead and participate in team meetings and training sessions, fostering collaboration and continuous improvement

• Model professionalism and respectful communication in all internal and external interactions

Qualifications – Required

• Experience and strong proficiency in Clinical Waste and Abuse

• Active, unrestricted RN license

• Minimum of 2 years of recent acute clinical nursing experience

• Demonstrated ability to independently manage complex clinical reviews and escalations

• Strong clinical judgment, problem-solving, and decision-making skills

• Knowledge of healthcare reimbursement principles and utilization review concepts

• Ability to communicate clearly and effectively across clinical and non-clinical audiences

Qualifications – Preferred

• Associate’s or Bachelor’s degree in Nursing

• Prior experience in clinical claims review, payment integrity, or utilization management

• Experience coaching, training, or mentoring peers

• Familiarity with NCQA and URAC guidelines

• Comfort working across multiple benefit plans and healthcare products

• Proficiency with Microsoft Office tools including Outlook and Excel

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 72,500 - 120,800 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.

At The Cigna Group, 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), 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, click here.

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 need a reasonable accommodation to complete the online application process, please email