Quality Review/Audit Specialist
The Cigna Group
full-time
Posted on:
Location Type: Remote
Location: California • United States
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Salary
💰 $68,700 - $114,500 per year
About the role
- Conduct Commercial HMO (non Medicare) claims audits to ensure compliance with DMHC regulations, federal and state requirements
- Review audit packages, including questionnaires and claims reports
- Coordinate with delegated provider groups on claim and dispute selections; verify accuracy of self-reported scores
- Perform onsite and virtual audits to assess operational security and identify compliance issues
- Analyze medical claims and disputes for regulatory adherence; prepare detailed audit reports
- Follow up on deficiencies, document corrective action plans, and conduct re-audits as needed
- Present audit results at Delegation Oversight Committee meetings
- Collaborate with functional areas (UM, Credentialing, Finance) on identified issues
- Monitor monthly self-reported statistics for assigned groups and ensure corrective actions are implemented
- Drive issue resolution by engaging cross-functional partners
- Serve as the primary liaison between Cigna’s Contracting & Provider Services Hub and delegated risk groups
Requirements
- Bachelor’s degree preferred
- 3+ years of claims auditing experience, ideally with capitated HMO products or providers
- Strong knowledge of claims payment methodologies, coding standards (Rev Code, CPT, DRG), and healthcare compliance regulations
- Knowledge of California Knox-Keene Act a plus
- Proficiency in Microsoft Word and Excel; experience preparing detailed reports
- Excellent interpersonal, verbal, and written communication skills
Benefits
- Comprehensive healthcare coverage (medical, dental, vision)
- 401(k) retirement plan with company match
- Paid time off and company holidays
- Tuition reimbursement and career development programs
- Employee wellness programs and mental health support
- Opportunities for advancement within a global organization
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
claims auditingclaims payment methodologiescoding standardsRev CodeCPTDRGhealthcare compliance regulationsaudit report preparationoperational security assessmentcorrective action plans
Soft Skills
interpersonal skillsverbal communicationwritten communicationcollaborationissue resolutionpresentation skills