Complex Claim Clinical Manager -Evernorth Health Services - Remote

Role Summary

The Complex Claim Clinical Manager provides strategic and operational leadership for the Complex Claim Unit (CCU) nursing teams, including Clinical Waste & Abuse (CWA), Clinical Complex Claim Review (CCR), and CCR Appeals. The role is accountable for achieving financial, quality, productivity, and timeliness objectives while ensuring a high level of customer satisfaction. This leader coaches and develops Health Services Managers, responds to internal and external inquiries, ensures compliance with regulatory and accreditation standards, and partners across business units to support enterprise initiatives.

Major Responsibilities

• Plan, organize, and manage resources and processes to achieve program objectives within defined scope, timelines, quality standards, and budget.
• Oversee utilization, clinical, and billing claim reviews; monitor quality outcomes and implement corrective actions as needed.
• Implement and monitor clinical edits and payment integrity programs.
• Develop, prioritize, and execute medical cost containment initiatives.
• Identify, recommend, and implement best practices to optimize operational efficiency and effectiveness.
• Establish departmental goals aligned with functional and enterprise strategies.
• Define, monitor, and report key production, quality, and financial performance metrics.
• Collaborate with Network Analytics, Coverage Policy, and Medical Directors to identify and implement savings and revenue opportunities.
• Provide subject-matter expertise and representation for Legal and Client Services related to clinical prepay programs.
• Guide and support clinical managers and medical directors involved in clinical prepay and postpay reviews.
• Evaluate and develop Health Services Managers, supporting performance improvement, skill development, and career progression.
• Lead automation, process improvement, and change initiatives to enhance efficiency, quality, and profitability.
• Promote inclusive hiring, retention, and leadership development practices.
• Manage workforce planning, capacity modeling, and financial forecasting to meet organizational targets.
• Ensure compliance with internal policies, product standards, and NCQA and URAC accreditation requirements.
• Conduct performance evaluations, deliver ongoing feedback, and manage compensation-related processes.
• Monitor and achieve key performance indicators and financial goals.
• Demonstrate cultural competence and professionalism in all interactions with staff, partners, clients, and customers.
• Leverage data analytics and business process engineering to drive continuous improvement.
• Stay current on industry trends and translate insights into actionable operational strategies.
• Participate in Payment Integrity initiatives and other assigned projects.

Qualifications & Experience

• Active Registered Nurse (RN) licensure required.
• Bachelor’s degree strongly preferred
• Advanced Degree is a plus
• A minimum of five years of experience managing clinical staff, including large or complex teams.
• Minimum of three years of cost containment experience required.
• Minimum of three (3) years of experience in utilization management, claim payment preferred.
• Demonstrated leadership, organizational, and people management capabilities.
• Strong analytical, problem-solving, and written and verbal communication skills.
• Proficiency with Microsoft Office and relevant clinical or business systems.
• Proven experience leading process improvement and change management initiatives.
• Ability to build and maintain effective relationships with internal and external stakeholders.
• Experience working in customer-focused, results-driven environments.
• Knowledge of performance measurement, data analysis, and reporting methodologies.
• Demonstrated ability to manage conflict and navigate complex organizational environments.
• Experience identifying and developing high-potential talent.
• Familiarity with data gathering, research methods, and information validation techniques.

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 130,700 - 217,800 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: 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.