Medical Claims Review Associate Analyst

Role overview

Responsibilities

• Provide members with information, navigation, and coordination related to covered benefits and medical needs.
• Assess treatment plans, identify care gaps and barriers, and flag risks of readmission or complications.
• Create documented, patient-centered case management plans with appropriate parties.
• Coordinate with members, caregivers, healthcare teams, providers, and internal partners.
• Identify expected outcomes and case closure criteria and promote communication among involved parties.
• Maintain intervention records, including cost-benefit analysis, savings, and data collection.
• Evaluate medical information against criteria, benefit plans, and coverage policies to determine medical necessity.
• Build working relationships with staff, functional partners, customers, and providers.
• Provide mentorship, support, and coverage to case management staff as appropriate.
• Assist Utilization Review, participate in training, and maintain clinical expertise through continuing education.
• Promote quality, cost-effective outcomes through education, health advocacy, and care coordination.

Minimum requirements

• Nurse licensure is required.
• Fluent reading, writing, and speaking English is required; additional languages are a plus.
• A BSc and MSc in Nursing, with Oncology specialization, is preferred.
• Strong organizational, leadership, interpersonal, communication, problem-solving, and analytical skills are required.
• Knowledge of utilization or case management, cost containment, managed care, insurance coverage, and financial management is preferred.
• Ability to advocate for customers while complying with internal policies, procedures, and contractual and legal requirements.
• Sensitivity to culturally diverse situations, clients, and customers.
• Ability to use a personal computer, Microsoft Office, call center software, and other software.
• Comply with applicable accreditation, state, federal, and local mandates and practice within licensure and certification scope.

About The Cigna Group