Complaint & Clinical Policy Advisor - MD Live - Hybrid

About the position The Medical Complaint & Clinical Policy Advisor is responsible for the day-to-day operations and continuous improvement of MD Live’s medical complaint and clinical policy functions. This role owns the end-to-end medical complaint lifecycle—intake, investigation, service recovery, resolution, and trend analysis—ensuring timely, high-quality responses and sustainable corrective actions that enhance the patient and provider experience. The Advisor also supports clinical policy governance across service lines, partnering with clinical, operational, and compliance stakeholders to develop, harmonize, and maintain evidence-based clinical policies. This role ensures data integrity, produces actionable insights, and drives policy education and adherence across the organization. What you’ll do to make a difference: Own the end-to-end medical complaint lifecycle using a dedicated complaint management system. Receive, document, and track complaints from multiple intake channels (e.g., phone, email). Lead investigations, identify root causes, and resolve complex or sensitive cases with an elite service mindset and urgency to meet service level agreements. Support clinical service recovery activities, including customer outreach and refund processing. Analyze complaint trends to recommend process, product, or policy improvements. Provide clear, confident communication to customers and internal stakeholders throughout resolution. Support drafting, harmonizing, and updating clinical policies across service lines in partnership with clinical leaders. Align policy language, scope, and terminology across MD Live offerings. Coordinate structured review and approval processes with Clinical Leadership, Legal/Compliance, and the Policy Committee. Partner with operations, nursing, and medical directors to implement policy changes and monitor adherence. Maintain integrity of complaint and clinical policy data within C360 and other systems. Develop KPI dashboards, root-cause analyses, and leadership-ready reporting. Oversee compliance testing and evaluate effectiveness of corrective actions. Rebuild and maintain the clinical policy education pathway. Deliver hands-on training and communications related to policy updates and regulatory changes. Participate in special projects and perform other duties as assigned.

Responsibilities

• Own the end-to-end medical complaint lifecycle using a dedicated complaint management system.
• Receive, document, and track complaints from multiple intake channels (e.g., phone, email).
• Lead investigations, identify root causes, and resolve complex or sensitive cases with an elite service mindset and urgency to meet service level agreements.
• Support clinical service recovery activities, including customer outreach and refund processing.
• Analyze complaint trends to recommend process, product, or policy improvements.
• Provide clear, confident communication to customers and internal stakeholders throughout resolution.
• Support drafting, harmonizing, and updating clinical policies across service lines in partnership with clinical leaders.
• Align policy language, scope, and terminology across MD Live offerings.
• Coordinate structured review and approval processes with Clinical Leadership, Legal/Compliance, and the Policy Committee.
• Partner with operations, nursing, and medical directors to implement policy changes and monitor adherence.
• Maintain integrity of complaint and clinical policy data within C360 and other systems.
• Develop KPI dashboards, root-cause analyses, and leadership-ready reporting.
• Oversee compliance testing and evaluate effectiveness of corrective actions.
• Rebuild and maintain the clinical policy education pathway.
• Deliver hands-on training and communications related to policy updates and regulatory changes.
• Participate in special projects and perform other duties as assigned.

Requirements

• Bachelor’s degree required.
• Project management or process improvement experience required.
• 2+ years of experience developing or supporting clinical policy in an ambulatory or inpatient setting.
• 5+ years of clinical or healthcare experience focused on improving patient satisfaction.
• Strong analytical, investigative, and critical-thinking abilities.
• Demonstrated service recovery, conflict resolution, and de-escalation skills.
• Ability to manage multiple priorities in a fast-paced, dynamic environment.
• Experience with SAIGlobal (C360), Tableau, Microsoft Office (Word, Excel, PowerPoint), and commercial EMR systems.
• Professional, adaptable, and collaborative approach to achieving clinical, operational, and strategic objectives.
• 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-haves

• Experience with C360 preferred.

Benefits

• 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.

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