Fraud Analyst

Overview

About Cigna Healthcare

About The Role

• As Medical Fraud 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)
• _What You’ll Do :_
• Identify and investigate potential instances of medical fraud, waste or abuse (FWA) or error across all Cigna’s International Markets books of business for claims incurred in a dedicated region. (KSA)
• Perform a variety of prepay focused cost avoidance activities.
• Seek recovery of FWA payments from claim submissions.
• 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.
• 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.
• _What You’ll Bring_
• 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.
• 3 - 5 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.
• _Skills :_
• 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.
• Please note that you must meet our posting guidelines to be eligible for consideration.
• Policy can be reviewed at this link.