Medical Fraud Senior Analyst Payment Integrity FWA

Overview

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.