Cigna Utilization Review Remote Jobs in Georgia (NOW HIRING)

Before applying, please note that this role is open exclusively to Registered Nurses (RNs).

Ready to take your clinical expertise to the next level - without leaving home?

MES Solutions is looking for a driven, high-performing Registered Nurse (RN) who’s eager for a role that’s both challenging and rewarding. If you love using your clinical judgment, have an eye for detail, and want to make a real impact behind the scenes, this could be the perfect fit.

As a Clinical Quality Assurance Coordinator, you’ll play a vital role in ensuring Peer Review case reports meet the highest standards of quality and integrity - while staying fully aligned with client expectations, regulatory requirements, and state and federal guidelines. Your expertise will help elevate outcomes and support excellence across the board.

Why you’ll love this role:

• 100% remote – work from the comfort of home
• Work-life balance with a structured, predictable schedule of Monday through Friday, 12:00pm-8:30pm EST
• A role that keeps your clinical skills sharp while offering something new and exciting

Responsibilities may include:

• Perform quality assurance review of peer review reports, correspondences, addendums or supplemental reviews.
• Ensure clear, concise, evidence-based rationales have been provided in support of all recommendations and/or determinations.
• Ensure that all client instructions and specifications have been followed and that all questions have been addressed.
• Ensure each review is supported by clinical citations and references when applicable and verifies that all references cited are current and obtained from reputable medical journals and/or publications.
• Ensure the content, format, and professional appearance of the reports are of the highest quality and in compliance with company standards.
• Ensure the appropriate board specialty has reviewed the case in compliance with client specifications or state mandates and is documented accurately on the case report.
• Verify that the peer reviewer has attested to only the facts and that no evidence of reviewer conflict of interest exists.
• Ensure the provider credentials and signature are adhered to the final report.
• Identify any inconsistencies within the report and contacts the Peer Reviewer to obtain clarification, modification or correction as needed.
• Assist in resolution of client complaints and quality assurance issues as needed.
• Ensure all federal ERISA and state mandates are adhered to at all times.
• Provide insight and direction to management on consultant quality, availability and compliance with all company policies and procedures and client specifications.
• Promote effective and efficient utilization of company resources.
• Participate in various educational and or training activities as required.
• Perform other duties as assigned.

• High school diploma or equivalent required.
• Active nursing license.
• A minimum of two years clinical or related field experience; or equivalent combination of education and experience.
• Knowledge of the insurance industry preferably claims management relative to one or more of the following categories: workers' compensation, no-fault, liability, and/or disability.
• Must have strong knowledge of medical terminology, anatomy and physiology, medications and laboratory values.
• Must be a qualified typist with a minimum of 40 W.P.M
• Must be knowledgeable of multiple software programs, including but not limited to Microsoft Word, Outlook, Excel, and the Internet.
• Must possess excellent skills in English usage, grammar, punctuation and style.
• Ability to follow instructions and respond to upper managements’ directions accurately.
• Demonstrates accuracy and thoroughness. Looks for ways to improve and promote quality and monitors own work to ensure quality is met.
• Must demonstrate exceptional communication skills by conveying necessary information accurately, listening effectively and asking questions where clarification is needed.
• Must be able to work independently, prioritize work activities and use time efficiently.
• Must be able to maintain confidentiality.

MES Solutions is a premier provider of independent medical examination and peer review services to the insurance, corporate, legal, and government sectors. Members of our credentialed medical panel conduct physical examinations or medical record reviews, delivering reports that assist clients in the resolution of automotive, disability, liability, and workers' compensation claims. MES has been providing services nationally since 1978 in accordance with the industry's highest standards of operating excellence and regulatory compliance.

MES offers a fast-paced team atmosphere with competitive benefits (medical, vision, dental), paid time off, and 401k.

Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, pregnancy, genetic information, disability, status as a protected veteran, or any other protected category under applicable federal, state, and local laws.