Medical Fraud Senior Analyst Payment Integrity FWA
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Key skills for this role
About the Role
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 K.
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
- Perform a variety of prepay focused cost avoidance activities
- Seek recovery of FWA payments from claim submissions
- Independently research and analyse data 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
- Ensure PI savings are tracked and reported accurately
- Negotiate 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
- Work on subrogation as needed for local claims in KSA in collaboration with Compliance team
Requirements
- Experience in fraud, waste, and abuse detection and recovery in healthcare claims
- Strong analytical and investigative skills
- Ability to perform data mining and identify trends
- Knowledge of healthcare claims processes and payment integrity
- Experience working with cross functional teams and TPAs
Full Job Posting
Job Description
- 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.
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.
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