Operating Effectiveness Analyst

Role Description

This role is responsible for driving ISO 9001-compliant internal audit practices across healthcare claims operations at CHSI Bangalore. The incumbent will ensure adherence to Quality Management Systems (QMS), strengthen operational controls, and enable a culture of continuous improvement, compliance, and audit readiness.

Key Responsibilities

ISO Audit & Compliance

• Plan and execute internal audits aligned to ISO 9001:2015 (Clause 9.2) and ISO 9001:2026
• Conduct process audits across the end-to-end claims lifecycle (intake → adjudication → payment → appeals)
• Perform gap assessments to evaluate compliance against QMS standards
• Ensure robust audit documentation, evidence validation, and traceability

Claims Process Oversight

• Assess claims accuracy, turnaround time (TAT), and policy adherence
• Audit critical processes, including:
  • Claims adjudication
  • Eligibility & enrolment validation
  • Denials & appeals management
• Identify process inefficiencies, control gaps, and operational risks

CAPA & Continuous Improvement

• Drive Corrective and Preventive Actions (CAPA) for audit findings
• Track closure of findings with quantifiable outcomes and timelines
• Partner with operations to standardize processes and drive quality improvements

Stakeholder Engagement

• Collaborate with:
  • Operations leadership
  • Quality assurance teams
  • Training and transition stakeholders
• Support external certification audits and regulatory reviews
• Develop audit reports, insights, and executive-ready summaries

Governance & Reporting

• Manage audit calendars, trackers, and compliance dashboards
• Publish insights on defect trends, risk indicators, and audit outcomes
• Support Management Review Meetings (MRMs) and governance forums

Candidate Profile

Education & Certifications

• Graduate (mandatory)
• Preferred certifications:
  • ISO 9001 Internal Auditor / Lead Auditor
  • Six Sigma Green Belt (or equivalent)

Experience

• 5–10 years of relevant experience in:
  • Healthcare BPO / US/International healthcare claims operations
  • Quality, audit, or compliance roles

Functional Expertise

• Strong understanding of:
  • US / International healthcare claims lifecycle
  • ISO 9001:2026 Quality Management System framework
• Demonstrated experience in:
  • Internal and process audits
  • CAPA management and closure
  • Compliance monitoring

Core Skills

• Audit planning and execution
• Root cause analysis and problem-solving
• Stakeholder management and influencing
• Documentation and reporting excellence
• Data analysis and dashboarding (Excel / reporting tools)

Behavioural Competencies

• High attention to detail and professional integrity
• Strong analytical and structured problem-solving mindset
• Ability to challenge and influence constructively
• Effective communication across cross-functional teams

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.