Complex Claim Clinical Manager
The Cigna Group
full-time
Posted on:
Location Type: Remote
Location: United States
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Salary
💰 $130,700 - $217,800 per year
About the role
- Provides strategic and operational leadership for the Complex Claim Unit (CCU) nursing teams
- Coaches and develops Health Services Managers
- Responds to internal and external inquiries
- Ensures compliance with regulatory and accreditation standards
- Partners across business units to support enterprise initiatives
- Plans, organizes, and manages resources and processes to achieve program objectives
- Oversees utilization, clinical, and billing claim reviews
- Implements and monitors clinical edits and payment integrity programs
- Develops, prioritizes, and executes medical cost containment initiatives
- Identifies, recommends, and implements best practices to optimize operational efficiency
- Establishes departmental goals aligned with functional and enterprise strategies
- Defines, monitors, and reports key production, quality, and financial performance metrics
- Collaborates with Network Analytics, Coverage Policy, and Medical Directors to identify and implement savings
- Provides subject-matter expertise and representation for Legal and Client Services related to clinical prepay programs
- Evaluates and develops Health Services Managers
- Leads automation, process improvement, and change initiatives
- Manages workforce planning, capacity modeling, and financial forecasting
- Ensures compliance with internal policies and product standards
- Conducts performance evaluations and manages compensation-related processes
- Leverages data analytics and business process engineering to drive continuous improvement
- Participates in Payment Integrity initiatives and other assigned projects
Requirements
- Active Registered Nurse (RN) licensure required
- Bachelor’s degree strongly preferred
- Advanced Degree is a plus
- A minimum of five years of experience managing clinical staff, including large or complex teams
- Minimum of three years of cost containment experience required
- Minimum of three (3) years of experience in utilization management, claim payment preferred
- Demonstrated leadership, organizational, and people management capabilities
- Strong analytical, problem-solving, and written and verbal communication skills
- Proficiency with Microsoft Office and relevant clinical or business systems
- Proven experience leading process improvement and change management initiatives
- Ability to build and maintain effective relationships with internal and external stakeholders
- Experience working in customer-focused, results-driven environments
- Knowledge of performance measurement, data analysis, and reporting methodologies
- Demonstrated ability to manage conflict and navigate complex organizational environments
- Experience identifying and developing high-potential talent
- Familiarity with data gathering, research methods, and information validation techniques
Benefits
- 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
- paid holidays
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
utilization managementcost containmentdata analyticsbusiness process engineeringclinical editspayment integrityperformance measurementdata analysisreporting methodologiesclinical staff management
Soft Skills
leadershiporganizational skillspeople managementanalytical skillsproblem-solvingcommunication skillsrelationship buildingconflict managementchange managementprocess improvement
Certifications
Registered Nurse (RN) licensure