Quality Review/Audit Sr Specialist

Cigna - Work at Home3.7

30+ days agoFull-time
Manage multiple supervisors, professionals and teams of quality and compliance monitors (auditors) in a virtual, fast paced environment. Manages production and effectiveness of staff and processes and the development and execution of process improvement plans. Partners with internal business owners to develop, implement, and maintain compliance based level 1 testing. Participates in the development and execution of remediation strategies. Maintains feedback databases and tools.

Responsibilities:
  • Organizes and manages monitoring quality assurance functions within team in close cooperation with the matrix business partners, customers, and with the Company’s Management team
  • Management of clinicians, pharmacists, and people managers in an organization of 35 plus.
  • Manage internal monitoring teams. Establish and monitor goals and metrics for each team.
  • Lead and support efforts to identify operational improvement opportunities that have a direct impact on the customer, provider, or vendor partner.
  • Ensure alignment of capacity and internal customer expectations. Build out capacity plans to understand overall staffing needs.
  • Responsible for the management of active test plans to ensure monitoring test plans address compliance risks, adjust with business needs, and are updated against iterative updates of guidelines and regulations.
  • Build collaborate relationships with business unit customers and ensure effective communication of monitoring results.
  • Responsible for the presentation of results to oversight committees such as Medical Management Committee, and the Corporate Delegation Oversight Committee.
  • Actively participates in SOX, CMS, and Internal Audits.
  • Ensure monitoring quality procedures, job aids, and methods are aligned with regulatory requirements and internal company policies.
  • Ensure staff development across multiple disciplines.
  • Formulates and manages the development and implementation of goals and objectives pertaining to quality monitoring teams
  • Utilizes results of analysis to suggest continuous improvement opportunities.
  • Will identify and implement quality metric, capture processes, and help evolve the quality metric dashboards
Qualifications

Qualifications

  • Bachelors Degree or equivalent experience required
  • At least 3 years of supervisory experience required
  • Managed care experience preferred
  • Coverage determination, Special Needs Plan, Case Management experience preferred
  • Strong experience in hiring, developing new teams and new operational processes strongly preferred.
  • Strong background with analyzing data, identifying trends to make business decisions
  • Background with statistical sampling and auditing concepts
  • Strong analytical and problem solving skills; must be able to systematically analyze and resolve complex problems cross organizationally.
  • Excellent organizational skills including proven ability to utilize resources, prioritize, manage and meet multiple deadlines with a quick turnaround time
Qualified applicants will be considered for employment without regard to age, race, color, religion, national origin, sex, sexual orientation, gender identity, disability, veteran status. Need an accommodation? Email: SeeYourself@cigna.com