Quality Review/Audit Specialist-Remote
About the Role: 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. Key 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. Qualifications: 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. Knowledge of California Knox-Keene Act a plus. Proficiency in Microsoft Word and Excel; experience preparing detailed reports. Excellent interpersonal, verbal, and written communication skills. 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 68,700 - 114,500 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 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 need a reasonable accommodation to complete the online application process, please email [email protected] for assistance. Please note that this email inbox is dedicated to accommodation requests only and cannot provide application updates or accept resumes. 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 To This Job