[Hiring] Quality Review/Audit Specialist @The Cigna Group

Role Description

The job profile for this position is Quality Review and Audit Lead Analyst, which is a Band 3 Senior Contributor Career Track Role.

About the Role:

• Cigna partners with over 150 delegated medical groups in California to process healthcare claims.
• The California Department of Managed Health Care (DMHC) enforces strict requirements for claims processing, provider disputes, and regulatory compliance.
• As a Remote Claim Delegation Auditor, you will ensure these delegated groups meet all state and federal healthcare regulations.
• Through claims audits, performance monitoring, and collaboration, you’ll help improve member experience and support cost-saving initiatives.

Key Responsibilities:

• 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.

Qualifications

• 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.
• 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.

Requirements

• For this position, we anticipate offering an annual salary of 68,700 - 114,500 USD / yearly, depending on relevant factors, including experience and geographic location.
• This role is also anticipated to be eligible to participate in an annual bonus plan.

Benefits

• Comprehensive range of benefits, with a focus on supporting your whole health.
• Health-related benefits including medical, vision, dental, and well-being and behavioral health programs starting on day one of your employment.
• 401(k), company paid life insurance, tuition reimbursement.
• A minimum of 18 days of paid time off per year and paid holidays.