The UM Clinical Reviewer Senior Analyst is responsible for concurrent review, care coordination, and utilization management activities across post-acute care settings. The role applies clinical judgment, evidence-based guidelines, and organizational policies to support quality outcomes, cost-effective care, and member experience.
Key Responsibilities- Implement, evaluate, and coordinate individualized plans of care for assigned members.
- Conduct utilization and concurrent reviews in alignment with medical necessity criteria and regulatory requirements.
- Collaborate with providers, Medical Directors, and interdisciplinary teams to support transitions of care.
- Identify gaps or deviations in care plans and intervene appropriately to support desired outcomes.
- Document clinical decisions, determinations, and communications accurately and timely in designated systems.
- Ensure compliance with The Cigna Group policies, accreditation standards, and confidentiality requirements.
- Participate in meetings, audits, and quality improvement initiatives as assigned.
Education, Licensure & Certification
- Current, unrestricted Registered Nurse (RN) license in state of residence; multistate license preferred.
- Associate or Bachelor's degree in Nursing preferred.
Experience Requirements
- Minimum of 2 years of clinical nursing experience.
- At least 2 years of utilization management or care management experience preferred.
- Experience in home health, skilled nursing, rehabilitation, or managed care environments preferred.
- Knowledge of Medicare and Medicaid managed care programs preferred.
Required Skills & Competencies- Strong time management and organizational skills.
- Clear and professional written and verbal communication abilities.
- Critical thinking and sound clinical decision-making.
- Ability to work independently with minimal supervision.
- Proficiency with Microsoft Office tools (Word, Excel, Outlook, PowerPoint) and virtual meeting platforms.
Work Environment & ConditionsThis is a remote, full-time position during core business hours, with flexibility to work shifts between 7:00 a.m. and 7:00 p.m. CST. Availability for weekend, on-call, and holiday rotation may be required.
The role requires the ability to sit for extended periods, utilize computer and telephone equipment, and perform occasional walking or standing.
Compliance StatementThis job description is intended to comply with The Cigna Group Job Description Requirements and applicable employment, accreditation, and regulatory standards. Duties and responsibilities may be adjusted to meet business needs.
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, paid holidays, and leaves of absence. For more details on our employee benefits programs, click here.
