Medical Fraud Senior Analyst Payment Integrity FWA Regional Team

Medical Fraud Senior Analyst –Payment Integrity FWA Regional Team

The job profile for this position is Medical Fraud Senior Analyst, which is a Band 3 Senior Contributor Career Track Role.

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Role Summary:

As Medical Fraud Senior Analyst within Payment Integrity FWA Team you will be directly supporting Cigna’s affordability commitment within Cigna International's business within KSA. This role is responsible for detecting and recovering FWA payments for non-network claims, creating solutions to prevent claims overpayment and future spend monitoring within a dedicated region. He/she will work closely with other PI team members, Network, Medical Economics, Data Analytics, Claims Operations, Clinical partners, Product and International Member Investigation Unit (MIU)

The position will report into the local KSA Head of Operations with functional reporting to broader Global Payment Integrity Team to provide adequate assurance and ensure alignment with
the Cigna group standards.

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

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.