[Hiring] Health Services Manager @The Cigna Group

Role Description

The Clinical Waste & Abuse (CWA) Complex Claim Program leader oversees pre- and post-pay medical record reviews to support accurate coding, billing, medical necessity determinations, and coverage decisions in alignment with the benefit plan and Cigna Medical and Reimbursement Policies. This leader manages and develops a team of Registered Nurses and drives a quality, cost-effective approach to high-cost claim review operations.

Key Responsibilities

• Hire, onboard, and retain staff; foster engagement and accountability.
• Monitor daily inventory, capacity, and financial performance to ensure alignment with goals.
• Serve as the subject matter expert for clinical pre-pay requests and key matrix partner needs.
• Coach the team on workflows, processes, and tools; reinforce best practices and quality standards.
• Track service metrics and quality results; review work regularly and take action to address trends and gaps.
• Set clear objectives and performance expectations for direct reports aligned to operational priorities.
• Provide ongoing performance coaching, career development support, and feedback; support talent planning and succession.
• Communicate effectively with stakeholders across the Complex Claim Unit, including Medical Directors and matrix partners.

Qualifications

• Active, unrestricted Registered Nurse (RN) license in state of residency.
• Three years of experience in Complex Claim Review (CCR) or Clinical Waste & Abuse (CWA) review.
• Experience with CCR/CWA operations, including high-dollar bill review.
• Three years of working knowledge of the insurance industry and end-to-end claims processes.

Preferred Qualifications

• Prior people leadership experience.
• Strong problem-solving skills with the ability to apply systems thinking to business solutions and manage change.
• Medical coding experience.
• Ability to manage multiple priorities, meet objectives, and maintain attention to detail.
• Proficient critical thinking and decision-making skills.
• Ability to think strategically, design action plans, and execute.
• Attention to detail.
• Detailed understanding of cover policies and reimbursement policies.
• Demonstrated strong leadership skills.
• Demonstrated excellence in the application of decision-making skills.
• Demonstrated ability to initiate, research, prioritize, plan, coordinate and organize.
• Excellent written and verbal communication and strong interpersonal skills.
• Proficiency in Microsoft Office (Excel, PowerPoint) and other common business tools.
• Knowledge of applicable state and federal statutes and regulations related to claim processing.
• Experience in training and staff development.
• Experience managing remote staff.

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 benefits focusing on supporting your whole health.
• Health-related benefits including medical, vision, dental, and well-being and behavioral health programs.
• 401(k) and company paid life insurance.
• Tuition reimbursement.
• A minimum of 18 days of paid time off per year and paid holidays.