Medical Fraud Senior Analyst –Payment Integrity FWA Regional Team
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Key skills for this role
About the Role
Cigna is seeking a Medical Fraud Senior Analyst to join the Payment Integrity FWA Regional Team in KSA. The role involves detecting and recovering fraud, waste, and abuse payments for non-network claims, performing data analysis, and collaborating with cross-functional teams.
Key Skills for This Role
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
- Provide investigation reports to internal and external stakeholders as per regulatory guidelines
Requirements
- Minimum of 4 years of health insurance or health care provider experience
- Experience of investigation within payment integrity or similar discipline
- Knowledge of claims coding, local regulatory rules and medical policy
- Fluency in Arabic in addition to fluent English
- Experience with data analytics
- Critical mindset with ability to identify cost containment opportunities
- Strong organization skills and attention to detail
- Excellent verbal and written communication skills
- Ability to balance multiple priorities and deliver on tight timelines
- Medical/paramedical qualification is a definite plus
Full Job Posting
Role Summary
- As Medical Fraud Senior Analyst within Payment Integrity FWA Team you will be directly supporting Cigna’s affordability commitment within Cigna Internationals 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.
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.
- Provide investigation reports to internal and external stakeholders as per regulatory guidelines.
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.
- Fluency in Arabic in addition to fluent English is a must.
About The Cigna Group
- Doing something meaningful starts with a simple decision, a commitment to changing lives.
- At The Cigna Group, we’re dedicated to improving the health and vitality of those we serve.
- Through our divisions Cigna Healthcare and Evernorth Health Services, we are committed to enhancing the lives of our clients, customers and patients.
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