Individual & Family Plans (IFP) Claims Strategy and Payment Integrity Senior Manager - Remote - Cigna Healthcare at Cigna in Bloomfield, Connecticut

Job Description:

The Claims Strategy and Payment Integrity Senior Manager will play an important role in our Affordability strategy by providing claim payment oversight for the Individual and Family Plans (IFP) segment. This individual will be responsible for identifying and driving claim payment integrity savings initiatives, monitoring and driving improvements in overall claim operations performance , and will assist in defining the strategic vision for IFP claim operations (claim platform, claim operations structure, etc.). This role requires a self-starter who can work closely with Claim Operations, Claim Utilization Management, Provider Operations, Product, IFP's Total Cost of Care team, IFP's Risk adjustment team, and other matrix partners to improve affordability within the segment. This individual will be able to align IFP claim administration activities against current industry policies/standards (especially IFP/Medicare/Medicaid). Additionally, this individual will lead a small team and report directly to the IFP Senior Director of Operations.

The role is designed for an individual who enjoys the challenge of working in a fast-paced environment with the ability to prioritize and influence key deliverables to deliver maximum impact.

Core Responsibilities:

• Liaison for Claim Operations and lead for claim administration.


• Collaborate with financial risk and analytics team and other partners to establish and/or monitor reports and analytics to identify and remediate spend leakage


• Drive delivery of solutions to prevent claim overpayments, unnecessary claim spend, and ensure timeliness and accuracy of claim administration.


• Evolve SLAs and oversees business partner claims processing and auditing to ensure SLAs are met, inclusive of accountability for Claims Monthly Operating Review, Claim Accuracy workgroup, and Claim Payment Integrity workgroup.


• Represent IFP in claim payment policy, process, and technology solutions to ensure IFP's unique needs are met


• Oversee the development and implementation of internal/external controls to ensure administrative cost-effectiveness, accurate and correct coverage determinations


• Review and interpret operational metrics (i.e. % pend, denied, paid, case mix, catastrophic claims expense, etc.) to assess need for procedural revisions and enhancements; participate in the design and implementation of specific systems to enhance claim adjudication processes.


• Have an excellent grasp of the claims system and overall workflow


• Keep up to date with carrier/coding/billing rule changes to ensure compliance with state regulations and/or provider contracts. Support operations application of rules to apply for pre and post pay claim edits and recovery identification and pursuit.


• Support development and implementation of long term claim operations strategic roadmap inclusive of claim platform, claim policies and processes, and claim operations model.


• Lead, coach, develop, and manage a small team of individuals to support employee development and strengthen IFP's claim performance.

Minimum Qualifications:

• Bachelor's degree preferred


• Minimum 10 years' health claim operations experience, including a minimum of 5 years' experience in ACA Claim Operations and/or Payment Integrity functions, such as claims editing, claim coding, enrollment, coordination of benefits, overpayment identification, claims auditing, pharmacy, Fraud, Waste and Abuse, and third party liability


• 7+ years management and leadership experience


• Experience building a claims team from the ground upisstrongly preferred


• Ability to communicate clearly and concisely with stakeholders in all facets of the business,including operations, finance, and legal. Must alsohave the ability tocommunicate at all levels,from customer service agents to senior leadership team.


• Strong project management skills and ability to meet aggressive deadlines, bias towards action


• Ability to proactively partner cross-functionally to solve complex business problems


• Strong prioritization skills, especially ina fast-moving environment


• Proficiency with designing process and workflows that streamline operations


• Ability to identify key metrics and manage to those metrics


• Out-of-the-box thinker who will find creative ways to solve problems with multiple stakeholders


• Experience working in a start-up environment andtheability to prioritize in a fast-moving environment

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 annual salary of 111,500 - 185,900 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.

We want you to be healthy, balanced, and feel secure. That's why 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) with company match, 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, visit Life at Cigna Group .

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 require reasonable accommodation in completing the online application process, please email: SeeYourself@cigna.com for support. Do not email SeeYourself@cigna.com for an update on your application or to provide your resume as you will not receive a response.

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.