Quality Review And Audit Senior Representative

YOUR JOB

As a Quality Review and Audit Senior Representative , you play a key role in safeguarding operational excellence across service delivery teams. You will be responsible for conducting quality audits, reviewing case accuracy, identifying process gaps, and ensuring adherence to internal procedures, regulatory guidelines, and customer commitments.

You will provide actionable feedback to team leaders and staff, support continuous improvement, and contribute to building a culture of quality, compliance, and consistency across Operations.

This role acts as a bridge between frontline teams, supervisors, and quality leaders by bringing insight, evidence-based recommendations, and root‑cause analysis into daily operations.

Key Responsibilities

Quality Review & Audit Execution

• Conduct routine and targeted audits across operational workstreams (e.g., Claims, Eligibility, Admin, Customer Service, Client Support).
• Assess accuracy, completeness, compliance, and alignment to SOPs and regulatory requirements.
• Review system entries, documentation, case handling, and communication quality.
• Ensure audit scoring is objective, consistent, and aligned with the quality framework.
  
  

Insights, Feedback & Coaching Support

• Provide clear, constructive audit feedback to team members and supervisors.
• Highlight high‑risk errors and recurring themes that require escalation.
• Support team leaders in delivering quality coaching sessions.
• Maintain accurate audit logs and records for reporting & governance.
  
  

Risk & Compliance Support

• Identify potential compliance gaps, regulatory breaches, or quality risks.
• Escalate critical findings promptly to supervisors and Quality leads.
• Support adherence to audit requirements for internal control, risk management, and governance processes.
  
  

Continuous Improvement

• Recommend improvements to processes, documentation, and training materials.
• Assist in revising SOPs or workflows when audit trends indicate the need for change.
• Identify opportunities for automation to improve process quality.
• Participate in mini‑projects or working groups aimed at service improvement.
  
  

Data & Reporting

• Define appropriate outcome-based metrics for aligned process
• Compile quality metrics, error trends, and monthly/quarterly dashboards.
• Support root‑cause analysis to identify systemic issues.
• Contribute to MOR input, audit summaries, and performance packs where required.
  
  

Cross‑Team Collaboration

• Work closely with supervisors, trainers, SMEs, transitions and QA colleagues to maintain consistent quality standards.
• Support readiness for new releases, process changes, training classes or quality framework updates.
• Participate in calibration sessions to ensure fairness and consistency of audit scoring.
  
  

YOUR PROFILE

• Minimum 3-5 years experience in an operations or quality‑related role.
• Strong understanding of operational processes (claims, eligibility, admin or service preferred).
• Good working knowledge of operational systems and tools (e.g., workflow systems, QA tools, CRM platforms, Excel).
• Excellent attention to detail and accuracy.
• Strong analytical capability with ability to interpret data and identify trends.
• Clear communicator, capable of giving balanced and constructive feedback.
• Ability to prioritise workload, manage deadlines, and work independently.
• Strong problem‑solving skills and process‑driven mindset.
• Customer‑focused, with a commitment to driving quality and service improvement.
• Fluent in English; additional languages are an advantage.
• Demonstrates integrity, fairness, and objectivity in audit assessment.
  
  

KEY COMPETENCIES

• Quality Orientation – Focuses on compliance, accuracy, and error‑free output.
• Analytical Thinking – Uses data, patterns, and root‑cause reasoning.
• Attention to Detail – Diligent and precise in reviewing casework.
• Collaboration – Builds constructive relationships with supervisors and staff.
• Communication – Provides clear written and verbal audit feedback.
• Time Management – Manages audit volumes and deadlines effectively.
• Process Discipline – Follows frameworks, SOPs, and governance standards.
• Continuous Improvement Mindset – Identifies improvement opportunities.
• Objectivity & Fairness – Ensures unbiased audit scoring.
• Customer Focus – Drives outcomes that protect customer experience.
  
  

About The Cigna Group

Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. Join us in driving growth and improving lives.

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