Cigna Hiring for Quality Review and Audit Manager– Payment Integrity Middle East & Africa Job at Dubai Full Time

Role Summary:
As a Quality Review & Audit Manager within the Payment Integrity (PI) fraud, waste and abuse (FWA) Team you will be directly supporting Cigna’s affordability commitment within Cigna International’s business. This role is responsible for leading remote, regionally focused (Middle East and Africa), Quality Assurance and Audit teams who are responsible for identifying and preventing fraudulent, wasteful and abusive expenses within Cigna’s International Business Market. The post holder will lead teams to develop and execute solutions to identify and prevent claims overpayments through FWA schemes. As an experienced professional and role model, you will perform/coordinate a variety of pre and post-pay focused loss prevention activities including identifying and investigating suspected aberrant behaviour, data-mining to reveal FWA trends and patterns and conduct Provider onsite and offsite audits. 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).

Responsibilities:
Lead the Quality Assurance and Audit team who are responsible for identifying and preventing fraudulent, wasteful and abusive expenses within Cigna’s International Business Market ensuring team targets and KPIs are met.

Works closely with PI FWA senior management to input into strategy and is responsible for executing departmental plans and priorities.

Ensure PI processes are in compliance with each countries healthcare system legal, regulatory and contractual requirements.

Effectively use business intelligence and data analytics to monitor PI FWA regional claim patterns and identifies opportunities for PI intervention and liaises with the Global Delivery Services Analytics Manager to develop FWA rulesets.

Apply and transfer FWA industry-knowledge to develop the FWA control environment.

Coach and support teams to monitor and identify non-compliance in billing and claims payment activity within the international markets.

Ensure department KPIs are met through effective monitoring and reporting mechanisms; ensure PI savings are tracked and reported accurately.

Accountable for managing internal stakeholder relationships where priorities may conflict.

Drives changes in policy and procedures in order to mitigate risk and represent PI FWA in key projects and initiatives across International Markets.

Identifies cost effective technologies, workflows and vendor partnerships necessary to meet PI strategic commitments.

Inform the GDS Service Effectiveness Manager of business requirements for specialist vendor support and supports with vetting operational capabilities for new payment integrity vendor offerings/expansions.

Assess work demand against capacity to ensure optimum claim referrals across all referral routes; create solutions, drive execution and ensure timeliness and accuracy of PI claims review process, loss prevention and recovery activity.

Instils work culture of continuous process improvement, innovation, and quality.

Oversee departmental personnel matters; evaluating staff performance and conducting performance appraisals for all direct reports. Ensure adherence to company practices and procedures.

Perform verification of services and charges and negotiate with providers contracted by Cigna or out-of-Network providers.

Provides input into workforce planning and recruitment activities and addresses resource and operational challenges.

Working closely with other departments to ensure Payment Integrity activities do not have an unnecessary negative impact on our customers.

Skills and Requirements:
Proven track record of leading global and remote operational teams.

Proven experience in influencing and coaching teams to identify and recover health plan overpayment.

Experience or background related to provider contract and/or claims leakage audit.

5+ years of health plan/medical claim investigation, compliance or fraud and abuse experience.

Knowledge of claims coding, regulatory rules and medical policy.

Global experience with minimum of one expertise in at least one market.

Medical/ paramedical qualification is a definite plus.

Knowledge of medical terminology and treatment modalities.

Critical mind-set with ability to identify cost containment opportunities. Effectively use data to inform key decision making and strategic direction (e.g. cost containment, projects and initiatives, staffing forecasts).

Strong data analytics tool(s) knowledge required.

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.

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.

About Cigna

Cigna Corporation exists to improve lives. We are a global health service company dedicated to improving the health, well-being and peace of mind of those we serve. Together, with colleagues around the world, we aspire to transform health services, making them more affordable and accessible to millions. Through our unmatched expertise, bold action, fresh ideas and an unwavering commitment to patient-centered care, we are a force of health services innovation. When you work with us, or one of our subsidiaries, you’ll enjoy meaningful career experiences that enrich people’s lives. What difference will you make?

Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.

If you require reasonable accommodation in completing the online application process, please email: [email protected] for support. Do not email [email protected] for an update on your application or to provide your resume as you will not receive a response.