As Medical Fraud Analyst within Payment Integrity FWA Team you will be directly supporting Cigna s affordability commitment within Cigna International's business within KSA.
This role is responsible for detecting and recovering FWA payments for non-network claims, creating solutions to prevent claims overpayment and future spend monitoring within a dedicated region. He/she will work closely with other PI team members, Network, Medical Economics, Data Analytics, Claims Operations, Clinical partners, Product and International Member Investigation Unit (MIU)
What You ll Do :
- Identify and investigate potential instances of medical fraud, waste or abuse (FWA) or error across all Cigna s International Markets books of business for claims incurred in a dedicated region. (KSA)
- Perform a variety of prepay focused cost avoidance activities.
- Seek recovery of FWA payments from claim submissions.
- Ensure PI savings are tracked and reported accurately.
- 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.
- Negotiation with out-of-Network providers.
- Perform data mining to reveal FWA trends and patterns.
- 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.
- Provide investigation reports to internal and external stakeholders.
- Abide by local regulations including but not limited to data residency restriction.
- Work on subrogation as needed for local claims in KSA in collaboration with Compliance team.
What You ll Bring
- You should enjoy working in a team of high performers, who hold each other accountable to perform to their very best.
- Experience of investigation within payment integrity or similar discipline.
- 3 - 5 years of health insurance or health care provider experience.
- Knowledge of claims coding, local regulatory rules and medical policy.
- Medical/ paramedical qualification is a definite plus.
Skills :
- 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.
Experience of investigation within payment integrity or similar discipline.
- 3 - 5 years of health insurance or health care provider experience.
- Knowledge of claims coding, local regulatory rules and medical policy.
- Medical/ paramedical qualification is a definite plus.
