Medical Claims Review Senior Analyst

Cigna Health and Life Insurance Company; Bengaluru; On-site; INR 900,000 - 1,500,000; Full time

Job summary

The Cigna Group in Bengaluru, India, seeks a Medical Claims Review Senior Analyst for the Complex Claim Unit. MBBS doctors with oncology experience will review high-dollar, complex claims and identify coding errors to ensure proper policy application.

Additionally, you will collaborate with Medical Directors and health care professionals. You will evaluate medical information against benefit plans, support fraud detection, and assist with training and escalation as needed.

Qualifications

• MBBS degree with active medical license.
• 3+ years clinical experience in hospital/clinic.
• Oncology experience preferred.

Responsibilities

• Evaluate medical information against criteria and policies.
• Review itemized bills for coding/billing accuracy.
• Adhere to quality assurance standards.
• Serve as a resource to explain products and policies.
• Assist with escalations and problem solving.
• Advise supervisory staff of concerns from Health Care Professionals.
• Communicate professionally in all interactions.
• Participate in special projects and random reviews.
• Support training and precepting as required.
• Identify and refer potential fraud/abuse cases.

Skills

Oncology

Claims review

Analytical thinking

Communication

Teamwork

Education

MBBS

Tools

MS Office Suite

Job description

Job Overview

Medical Claims Review Senior Analyst– Complex Claim Unit MBBS doctor with Oncology experience 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

Demonstrated expertise in Oncology, including hands-on experience with Chemotherapy and Radiotherapy services

• 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.