Quality Review and Audit Senior Advisor Job at The Cigna Group (Bloomington)

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

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Quality Review and Audit Senior Advisor

Job Description

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