Quality Review and Audit Senior Representative

This position will be responsible for auditing the work within the CGHB Organization.  As a member of the CGHB Quality Audit Team, the incumbent will have the ability and be expected to drive change, and positively impact the accuracy and efficiency of operations.

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.
• Excellent skills in navigation and use of all applications related to Diamond claim role including but not limited to: Diamond, SAM3, Outlook, CPF, Network X-Pricer, Salesforce, I Provider, Envoy, Facets, Visium, X-Net, Knowledge Xchange, PIMS (SANP), etc.
• 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

• 2+ years of overall experience processing claims, with at least 1+ year Diamond claim processing experience required. US & International claims experience preferred.
• 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.
• 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

Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. Join us in driving growth and improving lives.