Payment Integrity Prepay Fraud Supervisor

Quality Review and Audit Prepay Supervisor

The job profile for this position is Quality Review and Audit Supervisor which is a Band 3 Management Career Track Role.

Role Summary:

As a Quality Review & Audit Supervisor within the Payment Integrity Pre-Payment Team you will be directly supporting Cignas affordability commitment within Cigna Internationals business. This role is responsible for leading remote regionally focused prepayment team members who are responsible for identifying and preventing fraudulent wasteful and abusive expenses within Cignas International Business Market. He/ She will work closely with other PI team members Network Medical Economics Data Analytics Claims Operations Clinical partners and Member Investigations Unit (MIU).

Responsibilities:

• Lead the Regional Prepayment team who are responsible for identifying claims that should not be paid as received and identify claims with potential Fraud Waste and Abuse savings to meet Provider Integrity targets and KPIs.
• Works closely with Payment Integrity management to understand strategy and is responsible for executing departmental plans and priorities.
• Accountable for managing internal stakeholder relationships.
• Coach and support all PI Pre-Payment team members to monitor and identify non-compliance in billing and claims payment activity within the international markets.
• Ensure department KPIs are met through effective monitoring and reporting mechanisms; ensure PI savings are tracked and reported accurately.
• Executes strategic initiatives plans and goals in alignment with department KPIs and financial targets.
• Ensures payment integrity processes are in compliance with legal regulatory and contractual requirements.
• Assess work demand against capacity to ensure optimum claim referrals across all referral routes; create solutions drive execution and ensure timeliness and accuracy of PI claims review process.
• Instils work culture of continuous process improvement innovation and quality.
• Oversee departmental personnel matters; evaluating staff performance and conducting performance appraisals for all direct reports. Ensure adherence to company practices and procedures.
• Assist in organizing the on-boarding and training of new hires to the team.
• Perform verification of services and charges and in some cases negotiate with providers contracted by Cigna or out-of-Network providers.
• Recommends changes in policy and procedures in order to mitigate risk and participates in projects to improve business protocols.
• Provides input into workforce planning and recruitment activities and addresses resource and operational challenges.
• Providing feedback to other departments in order to put in place safeguards to prevent further risk exposure
• Working closely with other departments to ensure Payment Integrity activities do not have an unnecessary negative impact on our customers.

Skills and Requirements:

• Demonstrated strong organization skills
• Strong attention to detail
• Ability to quickly learn new and complex tasks and concepts
• Competent in processing or investigating claims on either the GlobalCare and or Actisure claim platforms
• Minimum of 2 years of health insurance or international health care provider experience.
• Minimum of 1 year of experience work in a Payment Integrity function preferred
• Fluency in foreign languages in addition to fluent English is a strong plus
• Knowledge of medical terminology and treatment modalities is a plus.
• Data analysis and reporting skills preferred
• Inquisitive nature capable of thinking critically and challenging assumptions
• Demonstrated follow through on complex problems and tasks
• Comfortable working independently and with a team
• Flexibility to work with global teams and varying time zones effectively.
• Ability to balance multiple priorities at once and deliver on tight timelines
• Ability to stay up to date on operations workflows
• Ability to develop and effectively communicate presentations and training materials
• Strong written and verbal communication skills
• Patience and creativity amongst your strong points
• Proficiency with Microsoft Excel needed. Word PowerPoint Outlook and SharePoint preferred
• Experience processing international claims preferred
• Comfort with telephonic outreaches to global entities preferred

About The Cigna Group