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.

Qualifications:

Overall 5+ years of experience in Healthcare Claim Adjudication process (in that min 1.5 years of auditing experience). 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.

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