Quality Review and Audit Advisor

POSITION SUMMARY

Provides expert content/professional leadership on complex Quality Assurance/Audit assignments/projects. Exercises considerable creativity, foresight, and judgment in conceiving, planning, and delivering initiatives. Leads efforts to identify operational improvement opportunities that have a direct impact on the customer, provider, or vendor partner. Typically responsible for issue evaluation and resolution and may be involved in developing and recommending changes in processing procedures. May be directly involved in complex operational audits or regulatory inquiries and provide expertise and guidance on technical or procedural issues. Uses deep professional knowledge and acumen to advise functional leaders. Focuses on providing thought leadership within Quality Review and Audit but works on broader projects, which require understanding of wider business. Recognized internally as a subject matter expert.

QUALIFICATIONS

• Healthcare Fraud Investigator (AHFI) designation from the National Health Care Anti-Fraud Association is required.

• 4 years of experience identifying Fraud Waste & Abuse (FWA) in the areas of prescription drugs and DME.

• Proficient with MS Excel (pivot table, VLOOKUP).

• Excellent communication skills. Will be conducting presentations and investigations via video/phone.

ESSENTIAL FUNCTIONS

• Answers Tipline and Emails.

• Utilizes workers’ compensation and investigative experience to perform data mining/analysis, identify trends or anomalies, and determine if there is any indication that SIU intervention will benefit the outcome of the claim. Makes decisions regarding course of action to identify potential fraud.

• Acts as the liaison and serves as a subject matter expert to facilitate investigations.

• Meets with healthcare providers as needed to determine if fraud exists.

• Develops and conducts FWA educational activities for internal and external customers.

• Analyze reports/data analytics, underlying file material, claims history, to determine if claim is suspect or potentially fraudulent.

• Maintaining and monitoring an active diary, properly documenting all developments in claim file, preparing investigative reports, maintaining suspicious claim database, and preparing reports on a quarterly basis to management.

• Performs investigations into potential and existing provider and patient fraud, waste and abuse activities. Identifies parties involved by reviewing inquiries and complaints against providers, members, facilities, pharmacies, groups, Conduct Interviews with providers, members or any other individual(s) necessary to complete an assigned investigation or special project. Determines the scope of the allegation or special project by assembling the necessary information, statistics, policies and procedures, licensure information, etc.

If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

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. Join us in driving growth and improving lives.

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: SeeYourself@cigna.com for support. Do not email SeeYourself@cigna.com for an update on your application or to provide your resume as you will not receive a response.

The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.