- 26003644
Role Summary
The Clinical Waste & Abuse (CWA) Complex Claim Program leader oversees pre- and post-pay medical record reviews to support accurate coding, billing, medical necessity determinations, and coverage decisions in alignment with the benefit plan and Cigna Medical and Reimbursement Policies. This leader manages and develops a team of Registered Nurses and drives a quality, cost-effective approach to high-cost claim review operations.
Key Responsibilities
- Hire, onboard, and retain staff; foster engagement and accountability.
- Monitor daily inventory, capacity, and financial performance to ensure alignment with goals.
- Serve as the subject matter expert for clinical pre-pay requests and key matrix partner needs.
- Coach the team on workflows, processes, and tools; reinforce best practices and quality standards.
- Track service metrics and quality results; review work regularly and take action to address trends and gaps.
- Set clear objectives and performance expectations for direct reports aligned to operational priorities.
- Provide ongoing performance coaching, career development support, and feedback; support talent planning and succession.
- Communicate effectively with stakeholders across the Complex Claim Unit, including Medical Directors and matrix partners.
Required Qualifications
- Active, unrestricted Registered Nurse (RN) license in state of residency.
- Three years of experience in Complex Claim Review (CCR) or Clinical Waste & Abuse (CWA) review.
- Experience with CCR/CWA operations, including high-dollar bill review.
- Three years of working knowledge of the insurance industry and end-to-end claims processes.
Preferred Qualifications
- Prior people leadership experience.
- Strong problem-solving skills with the ability to apply systems thinking to business solutions and manage change.
- Medical coding experience.
- Ability to manage multiple priorities, meet objectives, and maintain attention to detail.
- Proficient critical thinking and decision-making skills.
- Ability to think strategically, design action plans, and execute.
- Attention to detail
- Detailed understanding of cover policies and reimbursement policies.
- Demonstrated strong leadership skills.
- Demonstrated excellence in the application of decision-making skills.
- Demonstrated ability to initiate, research, prioritize, plan, coordinate and organize
- Excellent written and verbal communication and strong interpersonal skills.
- Proficiency in Microsoft Office (Excel, PowerPoint) and other common business tools.
- Knowledge of applicable state and federal statutes and regulations related to claim processing.
- Experience in training and staff development.
- Experience managing remote staff.
If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.
For this position, we anticipate offering an annual salary of 93,000 – 155,000 USD / yearly, depending on relevant factors, including experience and geographic location.
This role is also anticipated to be eligible to participate in an annual bonus plan.
At The Cigna Group, you’ll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you’ll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k), company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, click here.
About The Cigna Group
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.
Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.
If you need a reasonable accommodation to complete the online application process, please email [email protected] for assistance. Please note that this email inbox is dedicated to accommodation requests only and cannot provide application updates or accept resumes.
The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.
Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.
