Medical Fraud Senior Analyst –Payment Integrity FWA Regional Team

Overview

Role Summary

Responsibilities

• Identify and investigate potential instances of fraud, waste or abuse (FWA) or error across all Cigna’s International Markets books of business for claims incurred in a dedicated region.
• Perform a variety of prepay focused cost avoidance activities.
• Seek recovery of FWA payments from claim submissions.
• Independently and proactively research and analyse data while using appropriate investigative techniques to identify possible FWA cases.
• Identify Trends and Patterns of Insurance Fraud through analysis of data
• Work closely with investigative staff to further develop investigative leads and clearly articulate with meaningful action steps.
• Ensure PI savings are tracked and reported accurately.
• Work in partnership to implement solutions and drive execution to prevent claims overpayment, unnecessary claim spends and ensure timeliness and accuracy of PI claims review process.
• Negotiation with out-of-Network providers.
• Perform data mining to reveal FWA trends and patterns.
• 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 as per regulatory guidelines.
• Abide by local regulations including but not limited to data residency restriction.
• Work on subrogation as needed for local claims in KSA in collaboration with Compliance 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 claims coding, local 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 Arabic in addition to fluent English is a must.

About The Cigna Group