Registered Nurse, Clinical Waste & Abuse Reviewer - Cigna Healthcare - Remote

We are looking for a clinically experienced and forward-thinking Registered Nurse who is energized by improving healthcare quality and affordability. In this role, you will use your clinical judgment, analytical skills, and collaborative mindset to help reduce waste and abuse while protecting members and providers alike. You will be part of a team of ambitious and compassionate experts who believe better decisions today lead to better healthcare outcomes tomorrow.

Responsibilities

• Apply clinical expertise to evaluate medical records, claims, and documentation to determine medical necessity, coding accuracy, and alignment with coverage policies.
• Identify potential waste and abuse trends and translate insights into meaningful payment integrity opportunities.
• Partner closely with Medical Directors, the Complex Claim Unit, and matrix partners to support sound, defensible clinical decisions.
• Conduct both targeted and exploratory reviews across multiple products and benefit plans to improve pre-payment accuracy.
• Serve as a trusted clinical resource, helping internal teams understand clinical editing programs and review outcomes.
• Analyze complex clinical information and escalate high-risk or sensitive cases efficiently and professionally.
• Refer appropriate cases for potential fraud investigation, supporting a strong and ethical integrity framework.
• Communicate clearly and respectfully with providers, internal partners, and leadership to support shared goals.
• Contribute to continuous improvement initiatives, special projects, and evolving review strategies.
• Balance independent decision-making with strong teamwork, accountability, and quality standards.

Qualifications

Required Qualifications

• Current, unrestricted Registered Nurse (RN) license.
• Minimum of 2 years of clinical experience in an acute care setting.
• Associate degree in Nursing or Nursing Diploma.
• Strong clinical judgment, analytical thinking, and ability to apply policies consistently.
• Ability to manage multiple reviews and priorities with accuracy and efficiency.
• Clear written and verbal communication skills with a professional, collaborative approach.

Preferred Qualifications

• Bachelor’s degree in Nursing or related field.
• Prior experience in utilization review, claims review, or payment integrity.
• Knowledge of utilization management, reimbursement policies, and the insurance industry.
• Certified Professional Coder (CPC) or similar coding credential.
• Experience working across multiple benefit plans or products.
• Demonstrated comfort using clinical systems, job aids, and computer-based review tools.
• Proven ability to work independently while contributing positively to a team 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 66,200 - 110,400 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. 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 The Cigna Group 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. 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: [email protected] for support. Do not email [email protected] 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. Apply tot his job Apply To this Job