Provider Audit Senior Analyst

at  The Cigna Group

SKILLS AND REQUIREMENTS:

• Experience of influencing operational teams. You should enjoy working in a team of high performers, who hold each other accountable to perform to their very best.
• Minimum of 5 years of health insurance or international health care provider experience.
• 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.
• Experience with data analytics tool(s) is a strong asset.
• Knowledge of claims coding, regulatory rules and medical policy.
• Medical/ paramedical qualification is a definite plus.
• Knowledge of medical terminology and treatment modalities.
• Excellent verbal and written communication, interpersonal and negotiation skills.
• Ability to balance multiple priorities at once and deliver on tight timelines.
• Flexibility to work with global teams and varying time zones effectively.
• Confidence to deal with internal stakeholders and ability to work with a cross functional team.
• Strong organization skills with the ability to juggle priorities and work under pressure to meet tight deadlines.
• Dedicated to meeting the expectations and requirements of internal and external customers, excellent at building effective relationships and gaining trust and respect.
• Confidence to deal with internal stakeholders and ability to work across cross-functional teams.
• Fluency in foreign languages in addition to fluent English is a strong plus.

ROLE SUMMARY:

As a Provider Audit Senior Analyst within the International Payment Integrity Team, you will be directly supporting Cigna’s affordability commitment within Cigna International’s business. This role is responsible for three areas of accountability; 1) perform offsite (desktop) provider audit activity, 2) contribute to Payment Integrity oversight activities of Third Party/Cigna Links Vendors, 3) identify suspect provider activity across Cigna’s international market. You will also be expected to share your experience of clinical coding and billing abuse indicators with Payment Integrity peers. He/ She will work closely with other PI team members, Network, Medical Economics, Data Analytics, Claims Operations and Clinical partners.

RESPONSIBILITIES:

• Maintain Payment Integrity engagement timeline for Provider and TPA oversight, supporting Regional Managers to track notification, reporting and investigative timeframes.
• Perform provider desktop audit process across Cigna International Markets, ensuring processes are in compliance with legal, regulatory, and contractual requirements.
• Assist with the execution of TPA oversight reviews and ensure professional and quality standards are met across all vendor engagements.
• Work closely with PI FWA management to understand strategy and is responsible for executing departmental plans and priorities.
• In collaboration with the nominated regional investigator, produce investigative findings and recommendations to regional management for inclusion into reports to be shared with Providers and TPAs.
• Effectively use data to identify problem profiles and suspected aberrant provider billing behaviour.
• Support PI Regional teams to monitor PI FWA regional claim patterns using datamining techniques and identify opportunities for PI intervention, liaising with the Data & Analytics team to develop FWA rulesets.
• Support all PI FWA teams to monitor and identify instances of non-compliant provider billing and potential billing abuse within international markets claims exposure.
• Support the Audit Framework Senior Supervisor with maintaining standard operating protocols (SOPs) for Provider desktop audit and TPA Oversight processes.
• Execute strategic initiatives, plans, and goals in alignment with department KPIs and financial targets.
• Instil work culture of continuous process improvement, innovation, and quality.
• Recommend changes in policy and procedures in order to mitigate risk and participates in projects to improve business protocols.
• Working closely with other departments to ensure Payment Integrity activities do not have an unnecessary negative impact on our customers.