[Hiring] Clinical Waste & Abuse Nurse Lead @Cigna Healthcare

Role Description

As a Clinical Waste & Abuse Nurse Lead, you bring clinical expertise and thoughtful judgment to help protect patients, strengthen payment integrity, and support high-quality care. You play a critical role in identifying waste and abuse trends while coaching others and shaping smarter, more effective review practices.

• Lead complex clinical reviews that assess medical necessity, coding accuracy, and billing integrity to drive appropriate claim outcomes.
• Identify patterns, trends, and opportunities that strengthen cost containment and payment integrity initiatives.
• Serve as a trusted escalation partner for complex or non-routine cases, guiding resolution through sound clinical judgment.
• Coach, train, and mentor peers and new hires, helping build confidence, consistency, and clinical excellence.
• Partner with Medical Directors and cross-functional teams to advance high-quality, clinically sound decisions.
• Contribute to the development of tools, job aids, workflows, and documentation that improve efficiency and clarity.
• Lead and participate in team meetings and training sessions, fostering collaboration and continuous improvement.
• Model professionalism and respectful communication in all internal and external interactions.

Qualifications

• Experience and strong proficiency in Clinical Waste and Abuse.
• Active, unrestricted RN license.
• Minimum of 2 years of recent acute clinical nursing experience.
• Demonstrated ability to independently manage complex clinical reviews and escalations.
• Strong clinical judgment, problem-solving, and decision-making skills.
• Knowledge of healthcare reimbursement principles and utilization review concepts.
• Ability to communicate clearly and effectively across clinical and non-clinical audiences.

Requirements

• Associate’s or Bachelor’s degree in Nursing (preferred).
• Prior experience in clinical claims review, payment integrity, or utilization management (preferred).
• Experience coaching, training, or mentoring peers (preferred).
• Familiarity with NCQA and URAC guidelines (preferred).
• Comfort working across multiple benefit plans and healthcare products (preferred).
• Proficiency with Microsoft Office tools including Outlook and Excel (preferred).

Benefits

• Comprehensive range of health-related benefits including medical, vision, dental, and well-being and behavioral health programs.
• 401(k) plan.
• Company paid life insurance.
• Tuition reimbursement.
• A minimum of 18 days of paid time off per year and paid holidays.
• Annual salary range of 72,500 - 120,800 USD, depending on relevant factors.
• Eligibility to participate in an annual bonus plan.

Company Description

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.