Complex Claim Clinical Manager -Evernorth Health Services - Remote

Cigna Healthcare

6d • Remote

About The Position

Role Summary The Complex Claim Clinical Manager provides strategic and operational leadership for the Complex Claim Unit (CCU) nursing teams, including Clinical Waste & Abuse (CWA), Clinical Complex Claim Review (CCR), and CCR Appeals. The role is accountable for achieving financial, quality, productivity, and timeliness objectives while ensuring a high level of customer satisfaction. This leader coaches and develops Health Services Managers, responds to internal and external inquiries, ensures compliance with regulatory and accreditation standards, and partners across business units to support enterprise initiatives. Major Responsibilities Plan, organize, and manage resources and processes to achieve program objectives within defined scope, timelines, quality standards, and budget. Oversee utilization, clinical, and billing claim reviews; monitor quality outcomes and implement corrective actions as needed. Implement and monitor clinical edits and payment integrity programs. Develop, prioritize, and execute medical cost containment initiatives. Identify, recommend, and implement best practices to optimize operational efficiency and effectiveness. Establish departmental goals aligned with functional and enterprise strategies. Define, monitor, and report key production, quality, and financial performance metrics. Collaborate with Network Analytics, Coverage Policy, and Medical Directors to identify and implement savings and revenue opportunities. Provide subject-matter expertise and representation for Legal and Client Services related to clinical prepay programs. Guide and support clinical managers and medical directors involved in clinical prepay and postpay reviews. Evaluate and develop Health Services Managers, supporting performance improvement, skill development, and career progression. Lead automation, process improvement, and change initiatives to enhance efficiency, quality, and profitability. Promote inclusive hiring, retention, and leadership development practices. Manage workforce planning, capacity modeling, and financial forecasting to meet organizational targets. Ensure compliance with internal policies, product standards, and NCQA and URAC accreditation requirements. Conduct performance evaluations, deliver ongoing feedback, and manage compensation-related processes. Monitor and achieve key performance indicators and financial goals. Demonstrate cultural competence and professionalism in all interactions with staff, partners, clients, and customers. Leverage data analytics and business process engineering to drive continuous improvement. Stay current on industry trends and translate insights into actionable operational strategies. Participate in Payment Integrity initiatives and other assigned projects.

Requirements

• Active Registered Nurse (RN) licensure required.
• Bachelor’s degree strongly preferred
• A minimum of five years of experience managing clinical staff, including large or complex teams.
• Minimum of three years of cost containment experience required.
• Minimum of three (3) years of experience in utilization management, claim payment preferred.
• Demonstrated leadership, organizational, and people management capabilities.
• Strong analytical, problem-solving, and written and verbal communication skills.
• Proficiency with Microsoft Office and relevant clinical or business systems.
• Proven experience leading process improvement and change management initiatives.
• Ability to build and maintain effective relationships with internal and external stakeholders.
• Experience working in customer-focused, results-driven environments.
• Knowledge of performance measurement, data analysis, and reporting methodologies.
• Demonstrated ability to manage conflict and navigate complex organizational environments.
• Experience identifying and developing high-potential talent.
• Familiarity with data gathering, research methods, and information validation techniques.
• 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.

Nice To Haves

• Advanced Degree is a plus

Responsibilities

• Plan, organize, and manage resources and processes to achieve program objectives within defined scope, timelines, quality standards, and budget.
• Oversee utilization, clinical, and billing claim reviews; monitor quality outcomes and implement corrective actions as needed.
• Implement and monitor clinical edits and payment integrity programs.
• Develop, prioritize, and execute medical cost containment initiatives.
• Identify, recommend, and implement best practices to optimize operational efficiency and effectiveness.
• Establish departmental goals aligned with functional and enterprise strategies.
• Define, monitor, and report key production, quality, and financial performance metrics.
• Collaborate with Network Analytics, Coverage Policy, and Medical Directors to identify and implement savings and revenue opportunities.
• Provide subject-matter expertise and representation for Legal and Client Services related to clinical prepay programs.
• Guide and support clinical managers and medical directors involved in clinical prepay and postpay reviews.
• Evaluate and develop Health Services Managers, supporting performance improvement, skill development, and career progression.
• Lead automation, process improvement, and change initiatives to enhance efficiency, quality, and profitability.
• Promote inclusive hiring, retention, and leadership development practices.
• Manage workforce planning, capacity modeling, and financial forecasting to meet organizational targets.
• Ensure compliance with internal policies, product standards, and NCQA and URAC accreditation requirements.
• Conduct performance evaluations, deliver ongoing feedback, and manage compensation-related processes.
• Monitor and achieve key performance indicators and financial goals.
• Demonstrate cultural competence and professionalism in all interactions with staff, partners, clients, and customers.
• Leverage data analytics and business process engineering to drive continuous improvement.
• Stay current on industry trends and translate insights into actionable operational strategies.
• Participate in Payment Integrity initiatives and other assigned projects.

Benefits

• 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager