Medical Claims Review Analyst

Cigna Health and Life Insurance Company; India; On-site; INR 600,000 - 1,200,000; Full time

Job summary

Cigna Health and Life Insurance Company is seeking a Medical Claims Review Analyst for its Complex Claim Unit in India. The role involves clinical review of high-dollar and complex claims, evaluating bills against policies and ensuring proper coding and reimbursement procedures.

The position requires MBBS accreditation, 3+ years clinical experience, and strong analytical, time-management and communication skills.

Qualifications

• MBBS degree and active medical licensure as required by state/company guidelines.
• 3+ years clinical experience in hospital/clinic.
• Strong time management, organizational and research skills.

Responsibilities

• Evaluate medical information against criteria, benefit plan, coverage policies and determine necessity for procedures.
• Evaluate itemized bills against reimbursement policies.
• Handle escalated cases; seek supervisory assistance when needed.
• Identify potential fraud/abuse and refer cases to matrix partners.
• Participate in special projects and training activities.

Skills

Quantitative analysis

Interpersonal skills

Time management

Team player

Communication skills

Education

MBBS

Tools

MS Office Suite (Outlook, Excel, Access, SharePoint)

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* Performs additional unit duties below as appropriate: + 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.