Quality Review and Audit Senior Representative

Job Profile -

Quality Review and Audit Senior Representative

Job Description

Summary:

Technical expert with depth or breadth of knowledge within Quality Review and Audit. Applies standard techniques and procedures to routine instructions but requiring professional knowledge in specialist areas. Provides standard professional advice and creates initial reports/analyses for review. Develops and distributes audit reports. Assists with third party audits by completing questionnaires, validating selected claims, responding to errors, etc. Identifies and recommends changes to improvements in department processing and procedures and assists in the development of audit guidelines. May develop and/or recommend training programs to address error trends. Provides guidance, coaching, and direction to more junior team members of the team. Acts independently working under limited supervision.

Job Location:

Bengaluru, India (Work from office)

Work Shift:

US Shift - 17:00 to 02:00 IST

Responsibilities:

• Completes audits to ensure claim advocates understanding of current Cigna policies and procedures, including job aids, Articles, and alerts.  This includes claim processing guidelines, regulatory requirements, contractual benefits, and specific customer circumstances.

• Understanding of the appropriate application of claim and other directional documents/tools is a key component of the quality assurance auditing process.

• Interfaces with matrix partners in relation to quality audit process, specifically address gaps identified through audit process and recommendations for gap closure.

• Completes review of documents related to audits to help ensure direction is clear and consistent with processing of work.  Provides feedback to operations where updates may be required to drive consistency and accuracy.

• Completes inter-rater reliability exercises with peers, other quality roles and business owners to provide insight into review process.

• Understanding of the appropriate standard operating procedures and other directional documents/tools is a key component of the quality assurance auditing process.

• Provides a quality review voice in various workgroups pertaining to workflows, documentation and issues driving errors, in an attempt to continuously improve results.

• Supports, educates, and reinforces the workflows, processes, tools for the nurses.

• Provides support for internal and GSP sites based on business needs.

• Support Coaching and Training program and responsibilities when needed to Support for Business needs and requirements which could include answering Q&A, facilitate trainings, and Coaching’s.

Qualifications:

• Overall 3.5+ years of experience in Healthcare Claim Adjudication process. US & International claims experience preferred.

• At least 1+ year Diamond claim processing experience required.

• Customer Service Driven; ability to meet and exceed the internal partner and external customer expectations.

• Proven outcomes in critical thinking and decision-making outcomes.

• Proven outcomes in problem solving skills; utilization of technical skills and resources to ensure accuracy of final resolution.

• Proven process improvement skills: ability to assess trends, processes, and barriers to drive positive outcomes for claim resolutions.

• Must be comfortable and effective working in a diverse environment; office and/or virtual environment (if any).

• Strong organization and time management skills; effectively adapts to multiple and/or competing priorities.

• Strong communication skills, both verbal and written; ability to adapt communication to the individual or audience.

About The Cigna Group