Medical Claims Review Analyst

Cigna Health and Life Insurance Company; Bengaluru; On-site; INR 1,080,000 - 1,320,000; Full time

Job summary

The Cigna Group, Bengaluru, seeks a Medical Claims Review Analyst for its Complex Claim Unit. The role focuses on clinical review of high-dollar claims, identifying billing errors, enforcing policies, and flagging potential fraud.

You will collaborate with physicians and internal teams to ensure accurate reimbursement and prevent losses. Required is MBBS with active medical license and 3+ years of hospital/clinic exposure; familiarity with MS Office and strong communication skills are essential.

Qualifications

• MBBS degree and active medical license as required.
• 3+ years of clinical experience in hospital/clinic.
• Experience in health insurance utilization review or claim review preferred.
• Strong communication and organizational skills.

Responsibilities

• Evaluates medical information against criteria, benefit plan, coverage policies and determines necessity for procedure and refers to Medical Director if criteria are not met.
• Evaluate itemized bills against reimbursement policies.
• Adheres to quality assurance standards.
• Serves as a resource to facilitate understanding of products.
• Handles some escalated cases; secures supervisory assistance with problem solving and decision making.
• Advises supervisory staff of any concerns or complaints expressed by Health Care Professionals.
• Utilizes effective communication, courtesy and professionalism in all interactions, both internally and externally.
• Participate on special projects.
• Perform random or focused reviews as required.
• Support and assist with training and precepting as required.
• Analyze clinical information.
• Perform claim reviews with focus on coding and billing errors.
• Identify and refer cases for possible fraud/abuse or questionable billing practices to the appropriate matrix partners.
• Handle multiple products and benefit plans.
• Works under moderate direct supervision.

Skills

Medical claims review

Clinical expertise

MS Office

Communication skills

Team player

Time management

Education

MBBS

Medical license

Tools

MS Office Suite

Job description

Medical Claims Review Analyst- Complex Claim Unit

Provides clinical review expertise for high dollar and complex claims, including facility and professional bills. Provides cost containment services by identifying coding and billing errors and insuring application of Medical and Reimbursement Policies. Additionally identifies cases for potential fraud and abuse and makes referrals.

Major Job Responsibilities

• Evaluates medical information against criteria, benefit plan, coverage policies and determines necessity for procedure and refers to Medical Director if criteria are not met
• Evaluate itemized bills against reimbursement policies
• Adheres to quality assurance standards
• Serves as a resource to facilitate understanding of products
• Handles some escalated cases; secures supervisory assistance with problem solving and decision making
• Advises supervisory staff of any concerns or complaints expressed by Health Care Professionals
• Utilizes effective communication, courtesy and professionalism in all interactions, both internally and externally
• Participate on special projects.
• Perform random or focused reviews as required.
• Support and assist with training and precepting as required.
• Analyze clinical information
• Perform claim reviews with focus on coding and billing errors
• Identify and refer cases for possible fraud/abuse or questionable billing practices to the appropriate matrix partners
• Handle multiple products and benefit plans
• Works under moderate direct supervision

Qualifications

• MBBS
• Maintain active Medical as required by state and company guidelines
• Clinical experience in hospital/clinic for 3 or more years
• Team player
• Flexible/Adaptable
• Excellent time management, organizational, and research skills
• Experience with MS Office Suite (Outlook, Excel, Access, SharePoint)

Preferred Qualifications

• Utilization Review or Claim Review experience in Health insurance
• Knowledge of the Principles of Health Care Reimbursement

Key Skills and Competencies

• Strong background in quantitative decision making, ability to drive business/operations metrics
• Metrics-driven. Able to translate strategy into measurable operational goals and objectives.
• Disciplined in assessing performance and addressing problems.
• Good communication and strong interpersonal skills.
• Highly organized, structured & proactive.
• Good inter-cultural skills & Exposure to global work environment.
• Good time management skills - meet tight timelines and manage ad hoc deliverables, if any.

About The Cigna Group

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 with the information and insight they need to make the best choices for improving their health and vitality.

Join us in driving growth and improving lives.

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.