Fraud and Audit Manager

3 weeks ago

Glasgow, United Kingdom CIGNA European Services Full time

**Would you like to work for one of the leading halthcareinsurance providers in the world?**:

- **Would you like to benefot form a first class benefoit package?**

Cigna is looking to recruit a Fraud and Audit Manager to join our team, the role can be based naywhere in Europe as it is 100% remote.

Role Summary:
As a Fraud & Audit Manager within the Payment Integrity (PI) fraud, waste and abuse (FWA) Team you will be directly supporting Cigna’s affordability commitment within Cigna International's business. This role is responsible for leading remote, regionallyfocused (Americas and Europe), Quality Assurance and Audit teams who are responsible for identifying and preventing fraudulent, wasteful and abusive expenses within Cigna’s International Business Market. The post holder will lead teams to develop and executesolutions to identify and prevent claims overpayments through FWA schemes.

As an experienced professional and role model, you will perform/coordinate a variety of pre and post-pay focused loss prevention activities including identifying and investigating suspected aberrant behaviour, data-mining to reveal FWA trends and patternsand conduct Provider onsite and offsite audits. He/ She will work closely with other PI team members, Network, Medical Economics, Data Analytics, Claims Operations, Clinical partners, Product and International Markets Special Investigation Unit (SIU).

**Responsibilities**:

- Lead the Quality Assurance and Audit team who are responsible for identifying and preventing fraudulent, wasteful and abusive expenses within Cigna’s International Business Market ensuring team targets and KPIs are met.
- Works closely with PI FWA senior management to input into strategy and is responsible for executing departmental plans and priorities.
- Ensure PI processes are in compliance with each countries healthcare system legal, regulatory and contractual requirements.
- Effectively use business intelligence and data analytics to monitor PI FWA regional claim patterns and identifies opportunities for PI intervention and liaises with the Global Delivery Services Analytics Manager to develop FWA rulesets.
- Coach and support teams to monitor and identify non-compliance in billing and claims payment activity within the international markets.
- Accountable for managing internal stakeholder relationships where priorities may conflict.
- Drives changes in policy and procedures in order to mitigate risk and represent PI FWA in key projects and initiatives across International Markets.
- Identifies cost effective technologies, workflows and vendor partnerships necessary to meet PI strategic commitments.
- Inform the GDS Service Effectiveness Manager of business requirements for specialist vendor support and supports with vetting operational capabilities for new payment integrity vendor offerings/expansions.
- 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, loss prevention and recovery activity.
- Oversee departmental personnel matters; evaluating staff performance and conducting performance appraisals for all direct reports. Ensure adherence to company practices and procedures.
- Perform verification of services and charges and negotiate with providers contracted by Cigna or out-of-Network providers.
- Provides input into workforce planning and recruitment activities and addresses resource and operational challenges.
- Working closely with other departments to ensure Payment Integrity activities do not have an unnecessary negative impact on our customers.

Skills and Requirements:

- Proven track record of leading global and remote operational teams.
- Proven experience in influencing and coaching teams to identify and recover health plan overpayment.
- Experience or background related to provider contract and/or claims leakage audit.
- 5+ years of health plan/medical claim investigation, compliance or fraud and abuse experience.
- Knowledge of claims coding, regulatory rules and medical policy.
- Global experience with minimum of one expertise in at least one market.
- Medical/ paramedical qualification is a definite plus.
- Knowledge of medical terminology and treatment modalities.
- Critical mind-set with ability to identify cost containment opportunities. Effectively use data to inform key decision making and strategic direction (e.g. cost containment, projects and initiatives, staffing forecasts).
- Strong data analytics tool(s) knowledge required.
- .Fexibility to work with global teams and varying time zones effectively.
- Strong organization skills with the ability to juggle priorities and work under pressure to meet tight deadlines.
- Fluency in foreign languages in addition to fluent English is a strong plus.

**What’s in it for you?**
We recognise we wouldn’t be where we are today without our employees, that’s why we offer such excellent benefits designed to suit you as and when you need them:

- Attractive and competitive salary
- Remote working
- IT equipment is provided by us to allow you to work from home
- 30 days holiday per year - plus the option to buy/sell annual leave
- Pension - We believe saving for the future’s important, so you’ll benefit from auto-enrolment and a generous contribution from us
- Private Medical and Dental Insurance - with the option to add a partner or dependent(s) to your cover
- Life Assurance
- Well Being & EAP - Virtual workout class
- Incentive for recommending new staff
- Travel Insurance - Enjoy peace of mind while travelling abroad
- Flexible dress code - It’s not about what you wear, it’s about what you can do, and so why not be comfortable doing it
Plus much more

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