Quality Review/Audit Specialist-Remote

Job description

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 Delegati...