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