Quality Review & Audit Senior Manager-Claim Delegation Oversight at Cigna in Memphis, Tennessee

Job Description:

Position Overview

• Manages the team of External Delegation Claim Auditors and the Data Exchange Operations Liaison.


• Responsible for ensuring claim delegates meet compliance and regulatory requirements.


• Responsible for data exchange with capitated provider group performance, which is supplied by an external vendor. 


• Supports ad hoc projects that require claim delegation or data exchange expertise.  

National External Claim Delegation

• Manages the claim delegation team which includes 3 Senior Auditors (band 4) and 2 Auditors (band 3).


• Negotiates language changes to the claims delegation agreement as needed, and defines changes/additions that need to be made to the base templates.


• Provides guidance to national project teams on regulatory requirements and needed contractual language to support delegated arrangements.


• Advise market leadership for new HMO capitation markets on how to implement new capitation contracts involving claim delegation.  Works with contracting, provider services, claims and sales on determining major implementation milestones, as well as detailed employee training on capitation set-up and claim processing workflows for non-capitated services.


• Monitors state and federal regulatory changes in claims payment requirements, and implements updates to oversight tools as needed.


• Oversees claim delegation for the Cigna+Oscar alliance.


• Develop new claim delegation audit processes to support new contracting arrangements and value-based programs such as Ambulatory Surgery Center Bundled Payments program.

Vendor Management of prnLink.com

• Tracks financial performance of the external vendor and ensures compliance with contracting guidelines, including information protection requirements. Negotiates pricing for initial set-up of new delegates (as applicable) and per unit transactions.


• Manages the services the vendor provides for capitated groups with claim delegation.  Services provided are encounter data transfer, eligibility file transfer, benefit data transfer, misdirected outbound claims and capitation reporting


• Manages employee who monitors performance of the vendor and capitated provider group performance.


• Manages implementation of Client Specific Networks that have 3-tier benefit plans with an external vendor.  Establishes account set-up requirements and negotiates applicable fees with external vendor.


• Frequently consulted on system solution requirements for new products or CCC programs that involve risk.


• Participate on regulatory projects that involve the services provided by the external vendor (e.g.  accurately tracking impact of capitated services submitted on encounters for out-of-pocket accumulators).

Support California ad hoc projects

• Support California P4P quarterly reporting and payout requirements of the California IHA P4P program.

Policy

• Works closely with Compliance and National Contracting to identify and resolve issues requiring cross-
  functional solutions, policymaking and communication.


• Provides input and support to national projects (e.g. regulatory compliance initiatives, non-standard operations
  etc.) requiring cross functional problem solving, integration, prioritization and implementation.

Position Attributes

• Expertise in Enterprise Operations, Project Management, Delegation Vendor & Medical Group technical Operations, Health Plan Operations


• Ability to foster collaboration, value others perspectives and gain support and buy-in for organizational results.


• Matrix management leadership, subject matter expertise and influencing skills.


• Ability to drive and lead an organization through change.


• Excellent interpersonal and relationship management skills.


• Excellent organizational and technical/analytical skills that result in conclusive recommendations.


• Strong oral, written and presentation skills required.


• Strong collaboration and leadership skills.


• Ability to think critically with respect to improvement of end-to-end business process.

About Cigna

Cigna Corporation (NYSE: CI) is a global health service company dedicated to improving the health, well-being and peace of mind of those we serve. We offer an integrated suite of health services through Cigna, Express Scripts, and our affiliates including medical, dental, behavioral health, pharmacy, vision, supplemental benefits, and other related products. Together, with our 74,000 employees worldwide, we aspire to transform health services, making them more affordable and accessible to millions. Through our unmatched expertise, bold action, fresh ideas and an unwavering commitment to patient-centered care, we are a force of health services innovation.

When you work with Cigna, you’ll enjoy meaningful career experiences that enrich people’s lives while working together to make the world a healthier place. What difference will you make?  To see our culture in action, search #TeamCigna on Instagram.

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.

If you require reasonable accommodation in completing the online application process, please email: SeeYourself@cigna.com for support. Do not email SeeYourself@cigna.com for an update on your application or to provide your resume as you will not receive a response.