Senior Fraud Investigator

hace 1 semana


Madrid, Madrid, España Cigna A tiempo completo

Company Overview

Cigna is a global health insurance company that values its employees and strives to help them grow professionally. We are committed to our affordability commitment within Cigna International's business.

Job Description

As a Fraud Analyst within the Payment Integrity Team, you will directly support Cigna's affordability commitment. Your role involves detecting and recovering FWA payments, creating solutions to prevent claims overpayment, and future spend monitoring within a dedicated region (Americas geography, dedicated to the GIH Book of Business).

You will work closely with other PI team members, Network, Data & Analytics, Claims Operations, Clinical partners, Product, and Member Investigation Unit (MIU) to achieve this goal.

Responsibilities:

  • Investigate potential instances of fraud, waste, or abuse (FWA) across Cigna's International Markets books of business for claims incurred in a dedicated region.
  • Ensure PI savings are tracked and reported accurately.
  • Negotiate with providers contracted by Cigna or out-of-Network providers.
  • Review existing cases for any FWA trends and patterns.
  • Partner with Cigna TPAs on provider investigations.
  • Partner with Payment Integrity teams in other locations to share FWA claiming schemes.
  • Partner with Data Analytics team in building future FWA triggers automation.
  • Review FWA tools to support in identification of cases alongside senior investigators.
  • Adhere to turnaround times and timelines on investigations.
  • Contact providers and members requesting documents and confirming information.
  • Work with team members and manager to develop FWA cases.

Estimated Salary Range: $80,000 - $110,000 per year

Required Skills and Qualifications:

  • Working knowledge of GIH claims processes and systems.
  • Minimum of 2 years of health insurance or healthcare provider experience.
  • Knowledge of claims coding, regulatory rules, and medical policy.
  • Medical/paramedical qualification is a definite plus.
  • Critical mindset with ability to identify cost containment opportunities.
  • Experience with data analytics tool(s) is a strong asset.
  • Excellent verbal and written communication, interpersonal, and negotiation skills.
  • Ability to balance multiple priorities at once and deliver on tight timelines.
  • Flexibility to work with global teams and varying time zones effectively.
  • Confidence to deal with internal stakeholders and ability to work with a cross-functional team.
  • Strong organization skills with the ability to juggle priorities and work under pressure to meet tight deadlines.

Benefits:

Cigna offers a comprehensive benefits package, including health insurance, retirement plans, and paid time off.

Location: Americas geography, dedicated to the GIH Book of Business


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