Job Profile -
Quality Review and Audit Senior Representative
Job Description
Summary:
Technical expert with depth or breadth of knowledge within Quality Review and Audit. Applies standard techniques and procedures to routine instructions but requiring professional knowledge in specialist areas. Provides standard professional advice and creates initial reports/analyses for review. Develops and distributes audit reports. Assists with third party audits by completing questionnaires, validating selected claims, responding to errors, etc. Identifies and recommends changes to improvements in department processing and procedures and assists in the development of audit guidelines. May develop and/or recommend training programs to address error trends. Provides guidance, coaching, and direction to more junior team members of the team. Acts independently working under limited supervision.
Job Location:
Bengaluru, India (Work from office)
Work Shift:
US Shift - 17:00 to 02:00 IST
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 perks, 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 pro