Provider Audit Senior Analyst

Overview

Provider Audit Senior Analyst role at The Cigna Group. The job profile for this position is Quality Review and Audit Senior Analyst, a Band 3 Senior Contributor Career Track Role.

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 share experience of clinical coding and billing abuse indicators with Payment Integrity peers. You 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 execute 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 a culture of continuous process improvement, innovation, and quality.
• Recommend changes in policy and procedures in order to mitigate risk and participate in projects to improve business protocols.
• Work closely with other departments to ensure Payment Integrity activities do not have an unnecessary negative impact on our customers.

Skills And Requirements

About Cigna Healthcare

Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. Join us in driving growth and improving lives.

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 : for support. Do not email for an update on your application or to provide your resume as you will not receive a response.

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