Cigna is a global health service company, dedicated to helping the people we serve improve their health, well-being and sense of security. Cigna has almost 40,000 employees who service over 80 million customer relationships around the world. Within its international division, a dedicated unit - headquartered in Belgium - focuses on the needs of International...

Read more about this company

Role Purpose

Responsible to review and approve medical services requested by providers or customers according to medical necessity review guidelines. Will ensure customers receive the best quality care, diagnostics and treatment and avoid over or under-utilization of clinical services. Ability to review, investigate and respond to external and internal inquiries/complaints. Provide guidance to other clinical and non-clinical staff related to medical necessity.

Part of a clinical team that provides medical management services to customers worldwide but mainly in Africa region.

Give evidence-based advice on pre-authorization, considering internationally accepted protocols and local and/or regional customs and regulations.

Assessing pre-authorization requests claims in line with the policy coverage and medical necessity.

Identify and refer cases to the Cigna Clinical team for case management, disease management and other clinical services

Assist and support the team in cost containment, assist in projects and service delivery to meet goals.

To assist queries from providers and payers via phone calls or e-mails

Be fully versed with medical insurance policies for various groups / beneficiaries.

Might be required to assist in training colleagues and sharing knowledge.

Ability to review, investigate, and respond to external and internal inquires/complaints and provide guidance to other clinical and non-clinical staff related to medical necessity.

Assist in fraud detection

Meeting the defined qualitative and quantitative key performance metrics for the assigned job role.

Ensure adherence to the predefined TATs for pre-approvals

Achieving required targets assigned by the team leader on daily, weekly, and monthly basis.

Ensure compliance to any changes in terms of system parameters or process.

Other duties as assigned.

REQUIREMENTS

University Degree or Diploma in Medical specialization .

2-3 years of clinical experience preferable in a payer setting on medical management.

Experience in the Africa region & International market

Fluent in English along with either French, Portuguese or Spanish, any other language is a plus

Strong interpersonal and communication skills.

Must be a computer literate

Knowledge of utilization, cost containment services, insurance coverage.

Ability to build solid working relationships with staff, clients, customers, and healthcare providers.

Demonstrates pro-active problem-solving and analytical skills

Ability to work under pressure and meet tight deadlines

Flexible to work on shifts/varying work schedules.

• Review and approve medical services requested by providers or customers according to medical necessity review guidelines.
• Ensure customers receive the best quality care, diagnostics and treatment and avoid over or under-utilization of clinical services.
• Review, investigate and respond to external and internal inquiries/complaints.
• Provide guidance to other clinical and non-clinical staff related to medical necessity.
• Provide medical management services to customers worldwide but mainly in Africa region.
• Give evidence-based advice on pre-authorization, considering internationally accepted protocols and local and/or regional customs and regulations.
• Assess pre-authorization requests claims in line with the policy coverage and medical necessity.
• Identify and refer cases to the Cigna Clinical team for case management, disease management and other clinical services.
• Assist and support the team in cost containment, assist in projects and service delivery to meet goals.
• Assist queries from providers and payers via phone calls or e-mails.
• Be fully versed with medical insurance policies for various groups / beneficiaries.
• Assist in training colleagues and sharing knowledge.
• Assist in fraud detection.
• Meet the defined qualitative and quantitative key performance metrics for the assigned job role.
• Ensure adherence to the predefined TATs for pre-approvals.
• Achieve required targets assigned by the team leader on daily, weekly, and monthly basis.
• Ensure compliance to any changes in terms of system parameters or process.
• Perform other duties as assigned.

• Strong interpersonal and communication skills.
• Computer literate.
• Knowledge of utilization, cost containment services, insurance coverage.
• Ability to build solid working relationships with staff, clients, customers, and healthcare providers.
• Pro-active problem-solving and analytical skills.
• Ability to work under pressure and meet tight deadlines.
• Flexibility to work on shifts/varying work schedules.

• University Degree or Diploma in Medical specialization.
• 2-3 years of clinical experience preferable in a payer setting on medical management.
• Experience in the Africa region & International market.
• Fluent in English along with either French, Portuguese or Spanish, any other language is a plus.