Cigna Medicare Part C - Delegation Audit Specialist - Credentialing Focus (Compliance Specialist) in Houston, Texas


Role Summary

Implements compliance procedures and conducts complex audits of downstream entities (delegates) from a legislative / regulatory standpoint. Investigates and resolves complex compliance issues. Communicate with business owners and downstream entities to resolve issues.


  • Document, evaluate, and validate regulatory compliance with all requirements with the Centers for Medicare and Medicaid Services (CMS) Medicare Advantage Program, Prescription Drug Program, NCQA, and any other accreditation obtained by Cigna-HealthSpring.
  • Conduct external audits of downstream entities (delegates and related entities) for functions such as, but not limited to compliance program effectiveness, billing, case management, claims, contracting, credentialing, customer service, enrollment, physician review services, recovery services, sales & marketing, and utilization management to assess entity’s ability to perform and manage in accordance with regulatory, accreditation and health plan standards.
  • Simultaneously conduct multiple unrelated audits by function (e.g. compliance program effectiveness, billing, etc.) and type (e.g. desk, onsite etc.).
  • Promote Delegation Oversight initiatives with external and internal decision makers over multiple compliance functional areas.
  • Provides expert knowledge and guidance around Cigna delegation audit, Medicare, and NCQA compliance requirements.
  • Collaborate with downstream entities (delegates) on ways to improve adherence to regulatory requirements.
  • Oversee the Corrective Action Plans assigned to delegates and related entities.
  • Perform follow-up validation audits as required to assess improvement on previous noncompliant findings.
  • Execute assigned compliance, audit, and delegation projects to achieve the scope, timing, and objectives of each assignment.


Minimum Qualifications

  • Bachelor’s degree.
  • Three to five years or more of related compliance auditor experience.
  • Excellent organizational, analytical, project and time management skills.
  • Highly effective interpersonal, writing and communication skills required.
  • Familiarity and expertise with Medicare compliance requirements.
  • Ability to work independently with minimal supervision.
  • Multi-tasking and project Management skills.
  • Highly effective interpersonal and communication skills.
  • Flexible and able to adapt to changing priorities and required deadlines.
  • Must be able to work effectively with a variety of delegates and departments and leadership levels.
  • Must demonstrate exceptional customer service attitudes, including a “positive, can do” approach.

Preferred Qualifications

  • Clinical professional degree or licensure (Registered Nurse).
  • Previous compliance experience with state and federal regulatory requirements, Medicare Advantage health plan, Prescription Drug health plan, and Private Exchanges.
  • Previous delegation oversight, Utilization Management, or Claims experience.
  • Certified in Health Care Compliance (CHC) or other accredited compliance certification.

US Candidates Only:Qualified applicants will be considered for employment without regard to race, color, religion, national origin, sex, sexual orientation, gender identity, disability, veteran status. If you require a special accommodation, please visit our Careers website or contact us

Primary Location: Nashville-Tennessee

Other Locations: United States-Illinois-Chicago, United States-Texas-Plano, United States-Maryland-Baltimore, United States-Texas-Bedford, United States-Alabama-Birmingham, United States-Texas-Houston

Work Locations: 530 Great Circle Road Nashville 37228

Job: Legal--Compliance

Schedule: Regular

Shift: Standard

Employee Status: Individual Contributor

Job Type: Full-time

Job Level: Day Job


Job Posting: Oct 18, 2016, 3:35:29 PM