Senior Clinical Reviewer Analyst

This is a fully remote position, open to applicants in United States.

📋 Description

• Conduct utilization management assessments to evaluate medical necessity, appropriateness, and coverage benefits.

• Implement Cigna's medical guidelines, MCG standards, ASAM criteria, URAC regulations, and apply clinical judgment.

• Identify cases that necessitate physician evaluation and collaborate with Medical Directors accordingly.

• Initiate Case Management referrals when appropriate.

• Ensure adherence to HIPAA regulations, compliance rules, and internal quality benchmarks.

• Engage in team meetings, quality audits, training sessions, and enhancements to workflows.

• Assist with departmental initiatives, ensure documentation accuracy, and track performance metrics.

• Advocate for high-quality, cost-efficient medical services through clinical review processes.

• Complete assessments promptly to fulfill regulatory and contractual obligations.

• Uphold a professional representation of Cigna.

⛳️ Requirements

• Must be a Registered Nurse (RN) with a multistate license in good standing.

• Compact license is required.

• Bachelor of Science in Nursing (BSN) is preferred.

• A minimum of 2 years of RN experience in Cardiology, Oncology, ICU, or ER is necessary.

• Strong analytical, communication, and decision-making abilities are essential.

• Proficiency in Windows, Word, care management systems, and documentation platforms is required.

• Capability to manage multiple tasks, adhere to deadlines, and adapt to a fast-paced work environment.

• Must have a cable broadband or fiber optic internet connection with a minimum of 10Mbps download and 5Mbps upload speed for remote work.

🏝️ Benefits

• Eligible for an annual bonus plan.

• Medical, vision, and dental coverage available from the first day of employment.

• Access to well-being and behavioral health programs.

• 401(k) plan offered.

• Company-funded life insurance provided.

• Tuition reimbursement opportunities available.

• Minimum of 18 days of paid time off each year.

• Paid holidays included.

• Options for leaves of absence.

• Requirement for a cable broadband or fiber optic internet connection for remote work, with at least 10Mbps download and 5Mbps upload speeds.