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Role Description

The UM Clinical Reviewer Senior Analyst promotes quality and cost-effective medical services through clinical review, applying Cigna clinical policies, national guidelines, and decision-support tools to determine authorizations. The role ensures timely completion of reviews to meet regulatory and contractual requirements while representing Cigna professionally.

• Conduct utilization management reviews for medical necessity, appropriateness, and benefit coverage.
• Apply Cigna medical policies, MCG, ASAM, URAC standards, and clinical judgment.
• Identify cases requiring physician review and coordinate with Medical Directors.
• Initiate Case Management referrals as appropriate.
• Maintain compliance with HIPAA, regulatory rules, and internal quality standards.
• Participate in team meetings, quality audits, training, and workflow improvements.
• Support departmental initiatives, documentation accuracy, and performance metrics.

Qualifications

• Registered Nurse (RN) with multistate license in good standing.
• BSN preferred; Minimum 3 years RN experience in managed care, UM, or prior authorization.
• Strong analytical, communication, and decision-making skills.
• Proficiency with Windows, Word, care management platforms, and documentation systems.
• Ability to manage multiple tasks, meet deadlines, and adapt to a fast-paced environment.

Requirements

• 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.

Benefits

• Comprehensive range of health-related benefits including medical, vision, dental, and well-being and behavioral health programs.
• 401(k) with company paid life insurance.
• Tuition reimbursement.
• A minimum of 18 days of paid time off per year and paid holidays.
• Anticipated hourly rate of 31 - 52 USD, depending on relevant factors, including experience and geographic location.
• Eligibility to participate in an annual bonus plan.