What are the responsibilities and job description for the Medical Claims Review Senior Analyst position at The Cigna Group?
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Job Profile: Medical Claims Review Senior Analyst
Job Profile Summary Delivers specific delegated tasks assigned by a supervisor in the Medical Claims Review job family. Provides medical interpretation and decisions on identified health claims based on contractual benefits and medical circumstances and develops recommendations for resolution of questionable claims requiring further professional or committee review. Assesses the necessity and reasonableness of the items supplied in a valid claim through the use of medical policy and other materials such as documentation provided by the physician or other supplier. Applies clinical knowledge to assess the medical necessity, level of services, and appropriateness of care in cases requiring prospective, concurrent, or retrospective utilization review. Completes day-to-day Medical Review tasks without immediate supervision, but has ready access to advice from more experienced team members. Tasks involve a degree of forward planning and anticipation of needs/issues. Resolves non-routine issues escalated from more junior team members. Requires an RN.
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