Medical Claims Review Associate Analyst

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Skills you'll use

What you'll do

• Uses clinical knowledge to assess the treatment plan and goals and identifies gaps in care or risks for readmission or complications.
• Assesses member’s health status and treatment plan and identifies any gaps or barriers to healthcare.
• Establishes a documented patient centric case management plan involving all appropriate parties (client, physician, providers, employers, etc.)
• Interfaces with the member, family members/caregivers, and the healthcare team/provider, as well as internal matrix partners.
• Identifies anticipated case results/outcomes, criteria for case closure, and promotes communication within all parties involved.
• Maintains accurate record (system) of case management interventions including cost/benefit analysis, savings, and data collection.
• Evaluates medical information against criteria, benefit plan, coverage policies and determines medical necessity.
• Build solid working relationships with internal staff, matrix partners, key functional areas, customers, and providers
• Based on experience, may provide leadership, preceptor/mentorship, support and coverage to other case management staff and assist case managers in achieving positive outcomes and savings.
• Assists Utilization Review as needed/requested.

Who can apply

• Nurse Licensure. BSc & MSc Nursing
• Language skills: Fluent reading, writing and speaking English; any additional language is a plus.
• Demonstrated strong organizational and leadership skills.
• Strong interpersonal and communication skills.
• Demonstrates problem-solving and analytical skills.
• Knowledge of utilization or case management, cost containment services, managed care, insurance coverage, and financial management preferred.
• Ability to act as an “advocate” for the customer while complying with internal Policies and procedures and contractual/legal compliance requirements.
• Demonstrates sensitivity to culturally diverse situations, clients and customers.
• Compliant with all accreditations, State, Federal and local mandates.
• Ability to operate personal computer, proficient with Microsoft office products, call center software, and a variety of software.

About Cigna

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