Payment Integrity Prepay Fraud Supervisor

Overview

Quality Review and Audit Prepay Supervisor

The job profile for this position is Quality Review and Audit Supervisor, which is a Band 3 Management Career Track Role.

Role Summary

As a Quality Review & Audit Supervisor within the Payment Integrity Pre-Payment Team you will be directly supporting Cigna’s affordability commitment within Cigna International's business. This role is responsible for leading remote, regionally focused prepayment team members who are responsible for identifying and preventing fraudulent, wasteful and abusive expenses within Cigna’s International Business Market. He / She will work closely with other PI team members, Network, Medical Economics, Data Analytics, Claims Operations, Clinical partners, and Member Investigations Unit (MIU).

Responsibilities

• Lead the Regional Prepayment team who are responsible for identifying claims that should not be paid as received and identify claims with potential Fraud, Waste and Abuse savings to meet Provider Integrity targets and KPIs.
• Work closely with Payment Integrity management to understand strategy and is responsible for executing departmental plans and priorities.
• Accountable for managing internal stakeholder relationships.
• Coach and support all PI Pre-Payment team members 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.
• Executes strategic initiatives, plans, and goals in alignment with department KPIs and financial targets.
• Ensures payment integrity processes are in compliance with legal, regulatory and contractual requirements.
• 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.
• 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.
• Assist in organizing the on-boarding and training of new hires to the team.
• Perform verification of services and charges and in some cases negotiate with providers contracted by Cigna or out-of-Network providers.
• Recommends changes in policy and procedures in order to mitigate risk and participates in projects to improve business protocols.
• Provides input into workforce planning and recruitment activities and addresses resource and operational challenges.
• Providing feedback to other departments in order to put in place safeguards to prevent further risk exposure
• Working closely with other departments to ensure Payment Integrity activities do not have an unnecessary negative impact on our customers.

Skills and Requirements

About The Cigna Group

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.

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