Job Description

Position Title: Quality Review and Audit Senior Analyst

Job Purpose: Delivers specific delegated tasks assigned by a supervisor in the Quality Assurance/Audit job family. Completes day-to-day Quality Review and Audit tasks without immediate supervision, but has ready access to advice from more experienced team members. May assist in more complex audits where experience and wider business acumen is required. Contributes to the development of audit policies and procedures. Tasks involve a degree of forward planning and anticipation of needs/issues. Resolves non-routine issues escalated from more junior team members.

As Quality Review and Audit Senior Analyst within Payment Integrity FWA Team you will be directly supporting Cigna\'s affordability commitment within Cigna International\'s business. This role is responsible for detecting and recovering FWA payments, creating solutions to prevent claims overpayment and future spend monitoring within a dedicated region. He/She will work closely with other PI team members, Network, Medical Economics, Data Analytics, Claims Operations, Clinical partners, Product and International Markets Special Investigation Unit (SIU).

Reports to: Reporting to Director, Global Payment Integrity and FWA

Critical Tasks and Expected Contributions/Results:

• Identify and Investigate potential instances of fraud, waste or abuse (FWA) across all Cigna\'s International Markets books of business (excluding IO) for claims incurred in a dedicated region.
• Seek recovery of FWA payments from claim submissions.
• Ensure PI savings are tracked and reported accurately.
• Work in partnership to implement solutions and drive execution to prevent claims overpayment, unnecessary claim spend, and ensure timeliness and accuracy of PI claims review process.
• Negotiation with providers contracted by Cigna or out-of-Network providers.
• Perform data-mining to reveal FWA trends and patterns.
• Collaborate with the Special Investigation Unit on Fraud cases.
• Partner with Cigna TPAs on FWA investigations.
• Partner with Payment Integrity teams in other locations to share FWA claiming schemes.
• Partner with Data Analytics team in building future FWA triggers automation.
• Provide investigation reports to internal and external stakeholders.

Key Challenges/Anticipated Changes in Environment:

• Flexibility to work with global teams and varying time zones effectively.
• Strong organization skills with the ability to juggle priorities and work under pressure to meet tight deadlines.
• Ability to balance multiple priorities at once and deliver on tight timelines.

Developmental Value of Position:

• Experience of leading operational teams. You should enjoy working in a team of high performers, who hold each other accountable to perform to their very best
• Confidence to deal with internal stakeholders and ability to work with a cross functional team.

Skills and Requirements:

• You should enjoy working in a team of high performers, who hold each other accountable to perform to their very best.
• Experience of investigation within payment integrity or similar discipline.
• Minimum of 4 years of health insurance or health care provider experience.
• Knowledge of Globalcare, Actisure and/or Diamond essential.
• Knowledge of claims coding, regulatory rules and medical policy.
• Medical/ paramedical qualification is a definite plus.
• Critical mind-set with ability to identify cost containment opportunities.
• Experience with data analytics
• Demonstrated strong organization skills.
• Strong attention to detail.
• Ability to quickly learn new and complex tasks and concepts.
• Excellent verbal and written communication skills.
• Ability to balance multiple priorities at once and deliver on tight timelines.
• Flexibility to work with global teams and varying time zones effectively.
• Experience in liaising with internal stakeholders and ability to work independently within a cross functional team.
• Strong organization skills with the ability to juggle priorities and work under pressure to meet tight deadlines.
• Fluency in foreign languages in addition to fluent English is a strong plus.

Personal Competencies Required:

• Critical mind-set with ability to identify cost containment opportunities.
• Strong reporting and analytical skills with ability to create and improve reporting packs and methodologies with some support.
• Excellent verbal and written communication, interpersonal and negotiation skills.

-

Additional Information

Career Level

Not Specified

Qualification

Not Specified

Job Type

Full-Time

Job Specializations

,

Integrity Partners