UM Clinical Reviewer Senior Analyst - Work at Home

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. Core Responsibilities: 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 preferred. Previous in-patient or outpatient experience preferred. 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. Competencies Clinical Judgment & Decision Making Regulatory & Policy Compliance Communication & Collaboration Customer-focused Service Delivery Time & Workload Management 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. For this position, we anticipate offering an hourly rate of 31 - 52 USD / hourly, depending on relevant factors, including experience and geographic location. This role is also anticipated to be eligible to participate in an annual bonus plan. At The Cigna Group, you’ll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you’ll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k), company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, click here. About Cigna Healthcare Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. Join us in driving growth and improving lives. Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws. If you need a reasonable accommodation to complete the online application process, please email [email protected] for assistance. Please note that this email inbox is dedicated to accommodation requests only and cannot provide application updates or accept resumes. The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State. Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances. Doing something meaningful starts with a simple decision, a commitment to changing lives. 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. Join us in driving growth and improving lives.