Medical Fraud Senior Analyst –Payment Integrity FWA Regional Team

Role Overview

Medical Fraud Senior Analyst – Payment Integrity FWA Regional Team at Cigna. This is a Band 3 Senior Contributor Career Track Role based in the Kingdom of Saudi Arabia (KSA) within Cigna International's business.

Company Overview

The Cigna Group is dedicated to improving the health and vitality of those it serves. Through its divisions Cigna Healthcare and Evernorth Health Services, the company is committed to enhancing the lives of its clients, customers and patients.

Role Purpose

The Medical Fraud Senior Analyst directly supports Cigna's affordability commitment within Cigna International's KSA business by detecting and recovering Fraud, Waste and Abuse (FWA) payments for non-network claims, creating solutions to prevent claims overpayment, and implementing future spend monitoring within a dedicated region.

Key Responsibilities

Investigation and Detection

• Identify and investigate potential instances of fraud, waste or abuse (FWA) or error across all Cigna International Markets books of business for claims incurred in a dedicated region.
• Independently and proactively research and analyse data while using appropriate investigative techniques to identify possible FWA cases.
• Perform data mining to reveal FWA trends and patterns.
• Identify trends and patterns of insurance fraud through analysis of data.

Cost Avoidance and Recovery

• Perform a variety of prepay focused cost avoidance activities.
• Seek recovery of FWA payments from claim submissions.
• Work in partnership to implement solutions and drive execution to prevent claims overpayment, unnecessary claim spends and ensure timeliness and accuracy of PI claims review process.

Stakeholder Collaboration

• Work closely with other PI team members, Network, Medical Economics, Data Analytics, Claims Operations, Clinical partners, Product and International Member Investigation Unit (MIU).
• Work closely with investigative staff to further develop investigative leads and clearly articulate with meaningful action steps.
• Partner with Cigna TPAs on FWA investigations.
• Partner with Payment Integrity teams in other locations to share FWA claiming schemes.
• Partner with Data Analytics team in building future FWA triggers automation.
• Negotiate with out-of-Network providers.
• Work on subrogation as needed for local claims in KSA in collaboration with Compliance team.

Reporting and Compliance

• Ensure PI savings are tracked and reported accurately.
• Provide investigation reports to internal and external stakeholders as per regulatory guidelines.
• Abide by local regulations including but not limited to data residency restriction.

Qualifications & Experience

• Minimum of 4 years of health insurance or health care provider experience.
• Experience of investigation within payment integrity or similar discipline.
• Knowledge of claims coding, local regulatory rules and medical policy.
• Medical or paramedical qualification is a definite plus.

Skills & Competencies

• Critical mind-set with ability to identify cost containment opportunities.
• Experience with data analytics.
• Demonstrated strong organization skills.
• Strong attention to detail.
• Ability to quickly learn new and complex tasks and concepts.
• Excellent verbal and written communication skills.
• Ability to balance multiple priorities at once and deliver on tight timelines.
• Flexibility to work with global teams and varying time zones effectively.
• Experience in liaising with internal stakeholders and ability to work independently within a cross functional team.
• Strong organization skills with the ability to juggle priorities and work under pressure to meet tight deadlines.
• Fluency in Arabic in addition to fluent English is a must.
• Ability to work in a team of high performers who hold each other accountable to perform to their very best.

Additional Information

• The position reports to the local KSA Head of Operations with functional reporting to the broader Global Payment Integrity Team.
• 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.
• For reasonable accommodation in completing the online application process, email SeeYourselfEMEA@cigna.com for support.