Audit Specialist

Key Responsibilities

• Create Structured Audit Plan: Creating a robust yearly audit plan across all our external vendors, ensuring each one is properly audited within each year, with clear focus and objectives on the scope of audit.

• Conduct Audits: Ensuring all vendors are complying with the Cigna Supplier Code of Ethics. Monitoring and reviewing the vendor processing of the following activities in terms of TAT and accuracy and the alignment of this with the vendor's contractual agreement: Correct application of agreed price lists and discounts, including volume discounts, membership data processing and upload to the regulators systems, Product set up and benefit allocation, card production, Inpatient and outpatient Pre-approvals and the alignment of these with Cigna clinical guidelines, members and providers claim adjudication and payment against member benefits and Cigna policy terms and conditions/Cigna clinical guidelines, Members communication and Complaints investigation and resolution process and correct application of the agreed administration fees between Cigna and the Vendor(s). Part of the auditing will involve thorough reviews of data and/or it can be complemented through staff interviews/questioning.

• Recoveries: Through the Audit process, identifying any eligible recoveries with the applicable vendor and executing on Cigna receiving the recoveries in a timely manner, while working with internal stakeholders (UW, Finance, Actuarial) for visibility and any action.

• Review of Vendor Policies and data: Thorough review of Vendor(s) Business Continuity Plans, information protection, anti-bribery and corruption policies and procedures, policy set up records, details of pre-authorisations issued and claims settlements and SLA calculations.

• Identify Risks: Evaluate Operational, digital and financial processes, to identify potential risks, discrepancies, or irregularities in these and recommend appropriate corrective actions. Assessing the security of our data to ensure nothing is compromised.

• Audit Log and Reporting: Create, develop and maintain audit logs and comprehensive audit reporting for internal distribution and/or presenting to Senior Management that accurately reflect audit findings, conclusions, and recommendations for improvement.

• Compliance Monitoring: Monitor vendor adherence to all Regulatory Requirements, data protection and compliance and procedures as implemented/instructed by Cigna.

• Assess Controls: Evaluate the effectiveness of the vendor as well as internal controls and identify areas for enhancement to mitigate risks including system enhancement and training plans and ensure the vendor's compliance with the contractual agreement.

• Collaboration: Work closely with other departments to facilitate effective communication and support the implementation of audit recommendations.

• Continuous Improvement: Stay abreast of industry trends, best practices, and changes in regulations to continuously improve the audit process and maintain the highest level of expertise. Automating any process where possible.

• Knowledge development: In collaboration with the vendor's manager, act as a Subject Matter Expert (SME) in terms of activities managed by the administrator.

Qualifications and Requirements

• UAE National with family book.

• Education: Bachelor’s degree, preferably in nursing, pharmacy, dentistry, or medicine. Strong medical coding knowledge: professional certification in medical coding is a plus.

• Experience: Minimum of 3-5 years of experience in pre-authorisation, claims adjudication, and/or claims auditing.

• Language Skills: Proficiency in English and Arabic (both written and spoken) is required.

• Technical Skills: Strong knowledge of auditing standards, insurance regulations, and operational principles. With the ability to read and interpret documents such as plan of benefits, claims/approvals reports, vendor's contractual agreement, and procedural manuals and link these to the quality assurance activities. Proficiency in audit software and Microsoft Office Suite.

• Analytical Abilities: Exceptional analytical and problem-solving skills with a keen eye for detail.

• Communication Skills: Excellent verbal and written communication skills, with the ability to present complex information clearly and concisely.

• Interpersonal Skills: Strong interpersonal skills with the ability to work effectively in a team-oriented, fast-paced environment.

• Cross-Cultural Agility: Functions effectively across boundaries as intra-organizationally; picks up on cross-cultural nuances rapidly and translates this knowledge into successful approaches to work; demonstrates resourcefulness at accomplishing tasks despite local resistance; negotiates local and global interests sensitively, adeptly serving as a conduit between the two; is skillful at getting things done across the globe with little friction.

• Perseverance: Pursues everything with energy, drive, and a need to finish; seldom gives up before finishing, especially in the face of resistance or setbacks.

• Ethics and Integrity: Demonstrated ethical behaviour and a commitment to maintaining the highest standards of integrity and professionalism.