Medical Claims Review Sr Analyst

Evernorth; Bengaluru; On-site; INR 900,000 - 1,300,000; Full time

Job summary

The Cigna Group in Bengaluru seeks a Medical Claims Review Senior Analyst for its Complex Claim Unit. The role requires MBBS with oncology experience to review high-value claims, ensure policy compliance, and guide case referrals.

Responsibilities include validating clinical data against coverage policies, identifying billing errors, and supporting fraud detection while coordinating with medical directors and supervisors as needed.

Qualifications

• MBBS with active medical license as required by state and company guidelines.
• Clinical experience in hospital/clinic for 3+ years.

Responsibilities

• Provides clinical review for high-dollar and complex claims, ensuring adherence to Medical and Reimbursement Policies.
• Evaluates itemized bills against reimbursement policies and determines necessity for procedures.
• Identifies cases for potential fraud/abuse and makes referrals to appropriate parties.
• Handles escalated cases and seeks supervisory guidance when needed.
• Supports training and precepting of others and participates in special projects.

Skills

Oncology expertise

Quantitative decision making

Communication skills

Time management

Education

MBBS

Medical license

Tools

MS Office Suite

Job description

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 plansWorks 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.

Disclaimer: This job posting has been aggregated from external source. Role details, content, and availability are subject to change. Applicants are advised to confirm the latest information directly on the company website before applying.