Quality Review/Audit Specialist-Remote

Cigna Healthcare

2d•Remote

About The Position

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.

Requirements

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.
Proficiency in Microsoft Word and Excel; experience preparing detailed reports.
Excellent interpersonal, verbal, and written communication skills.

Nice To Haves

Bachelor’s degree preferred.
Knowledge of California Knox-Keene Act a plus.

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.