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Quality Review and Audit Senior Advisor

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The Cigna Group

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Location:
United States of America , Bloomington

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Category:
Quality Control

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Contract Type:
Employment contract

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Salary:

100000.00 - 166600.00 USD / Year
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Job Description:

The Quality Review & Senior Audit Advisor provides enterprise-level quality assurance leadership with a strong focus on clinical accuracy, pharmacy benefit integrity, and regulatory compliance. This role applies advanced clinical and pharmacy expertise to validate benefit configurations, evaluate clinical program performance, and ensure alignment with CMS, NCQA, and state regulatory requirements across processes, systems, and training programs.

Job Responsibility:

  • Provide expert clinical and pharmacy oversight for quality monitoring and testing across Medicare, Medicaid, and Exchange (HIM) lines of business
  • apply clinical judgment and pharmacy expertise to assess benefit configurations, clinical rules, and pharmacy setups for accuracy, safety, and compliance
  • validate pharmacy benefit designs, including formularies, prior authorization criteria, step therapy, quantity limits, and utilization management logic
  • interpret clinical documentation, policies, and regulatory guidance to ensure correct implementation within systems and operational workflows
  • lead and co-lead end-to-end clinical and pharmacy benefit testing for new implementations, benefit changes, and remediation initiatives
  • evaluate clinical program integrity, including medication therapy management, adherence programs, utilization management, and quality initiatives
  • identify clinical and pharmacy risks, defects, and configuration gaps
  • document findings and drive resolution through cross-functional collaboration
  • ensure testing outcomes align with CMS regulations, NCQA standards, and state-specific clinical and pharmacy requirements
  • serve as a trusted advisor on regulatory interpretation, translating complex clinical and pharmacy guidance into actionable testing and configuration requirements
  • support audits, client inquiries, and regulatory requests with defensible, clinically sound documentation and analysis
  • analyze clinical and pharmacy data to identify trends, quality gaps, and improvement opportunities
  • use data-driven insights to inform process improvements, control enhancements, and preventive quality strategies
  • develop and maintain clinically focused quality controls, testing templates, and standardized procedures
  • partner closely with Clinical, Pharmacy, Operations, PMO, Product, and Technology teams to ensure accurate execution of requirements
  • communicate complex clinical and pharmacy concepts clearly to non-clinical stakeholders, including risks, impacts, and recommended actions
  • mentor and train team members on clinical reasoning, pharmacy benefit structures, and regulatory expectations
  • demonstrate leadership while managing multiple complex initiatives and maintaining high standards of quality and accountability

Requirements:

  • Bachelor's degree strongly preferred
  • clinical, pharmacy, nursing, or healthcare-related background strongly preferred
  • management experience required, with a demonstrated ability to lead and develop high-performing teams
  • strong analytical, data management, and technical skills
  • advanced proficiency with Microsoft Office Suite
  • excellent verbal and written communication skills, with the ability to explain complex clinical and pharmacy concepts clearly
  • 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

Nice to have:

  • experience with agile methodologies a plus
  • financial acumen and understanding of healthcare cost drivers preferred
What we offer:
  • medical
  • vision
  • dental
  • well-being and behavioral health programs
  • 401(k)
  • company paid life insurance
  • tuition reimbursement
  • a minimum of 18 days of paid time off per year
  • paid holidays

Additional Information:

Job Posted:
May 20, 2026

Employment Type:
Fulltime
Work Type:
Hybrid work
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