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.
Clinical Waste & Abuse Nurse Reviewer
Location
United States
Posted
1 day ago
Salary
Not specified
No structured requirement data.
Job Description
Role Description
We are looking for a clinically experienced and forward-thinking Registered Nurse who is energized by improving healthcare quality and affordability. In this role, you will use your clinical judgment, analytical skills, and collaborative mindset to help reduce waste and abuse while protecting members and providers alike. You will be part of a team of ambitious and compassionate experts who believe better decisions today lead to better healthcare outcomes tomorrow.
- Apply clinical expertise to evaluate medical records, claims, and documentation to determine medical necessity, coding accuracy, and alignment with coverage policies.
- Identify potential waste and abuse trends and translate insights into meaningful payment integrity opportunities.
- Partner closely with Medical Directors, the Complex Claim Unit, and matrix partners to support sound, defensible clinical decisions.
- Conduct both targeted and exploratory reviews across multiple products and benefit plans to improve pre-payment accuracy.
- Serve as a trusted clinical resource, helping internal teams understand clinical editing programs and review outcomes.
- Analyze complex clinical information and escalate high-risk or sensitive cases efficiently and professionally.
- Refer appropriate cases for potential fraud investigation, supporting a strong and ethical integrity framework.
- Communicate clearly and respectfully with providers, internal partners, and leadership to support shared goals.
- Contribute to continuous improvement initiatives, special projects, and evolving review strategies.
- Balance independent decision-making with strong teamwork, accountability, and quality standards.
Qualifications
- Current, unrestricted Registered Nurse (RN) license.
- Minimum of 2 years of clinical experience in an acute care setting.
- Associate degree in Nursing or Nursing Diploma.
- Strong clinical judgment, analytical thinking, and ability to apply policies consistently.
- Ability to manage multiple reviews and priorities with accuracy and efficiency.
- Clear written and verbal communication skills with a professional, collaborative approach.
Requirements
- Bachelor’s degree in Nursing or related field.
- Prior experience in utilization review, claims review, or payment integrity.
- Knowledge of utilization management, reimbursement policies, and the insurance industry.
- Certified Professional Coder (CPC) or similar coding credential.
- Experience working across multiple benefit plans or products.
- Demonstrated comfort using clinical systems, job aids, and computer-based review tools.
- Proven ability to work independently while contributing positively to a team environment.
Benefits
- Comprehensive range of benefits, with a focus on supporting your whole health.
- Health-related benefits including medical, vision, dental, and well-being and behavioral health programs.
- 401(k), company paid life insurance, tuition reimbursement.
- A minimum of 18 days of paid time off per year and paid holidays.
Job Requirements
- Current, unrestricted Registered Nurse (RN) license.
- Minimum of 2 years of clinical experience in an acute care setting.
- Associate degree in Nursing or Nursing Diploma.
- Strong clinical judgment, analytical thinking, and ability to apply policies consistently.
- Ability to manage multiple reviews and priorities with accuracy and efficiency.
- Clear written and verbal communication skills with a professional, collaborative approach.
- Bachelor’s degree in Nursing or related field.
- Prior experience in utilization review, claims review, or payment integrity.
- Knowledge of utilization management, reimbursement policies, and the insurance industry.
- Certified Professional Coder (CPC) or similar coding credential.
- Experience working across multiple benefit plans or products.
- Demonstrated comfort using clinical systems, job aids, and computer-based review tools.
- Proven ability to work independently while contributing positively to a team environment.
Benefits
- Comprehensive range of benefits, with a focus on supporting your whole health.
- Health-related benefits including medical, vision, dental, and well-being and behavioral health programs.
- 401(k), company paid life insurance, tuition reimbursement.
- A minimum of 18 days of paid time off per year and paid holidays.
