Financial Crime Prevention Specialist

hace 1 semana


Madrid, Madrid, España Cigna A tiempo completo

Anti-Fraud and Waste Analyst

Cigna Healthcare is committed to providing quality healthcare services to its customers. As an Anti-Fraud and Waste Analyst within Payment Integrity Team, you will play a crucial role in identifying and preventing fraudulent activities that can compromise the integrity of our healthcare system.

This role is responsible for analyzing claims data to detect potential instances of fraud, waste or abuse (FWA), and collaborating with various teams to implement solutions to prevent claims overpayment and future spend monitoring within a dedicated region (Americas geography, dedicated to the GIH Book of Business).

Key Responsibilities:

  1. Conduct thorough analysis of claims data to identify potential instances of FWA.
  2. Develop and implement strategies to prevent claims overpayment and future spend monitoring.
  3. Negotiate with providers contracted by Cigna or out-of-Network providers.
  4. Collaborate with Cigna TPAs on provider investigations.
  5. Share FWA claiming schemes with Payment Integrity teams in other locations.
  6. Work with Data Analytics team to build future FWA triggers automation.
  7. Review FWA tools to support in identification of cases.
  8. Adhere to turnaround times and timelines on investigations.
  9. Contact providers and members requesting documents and confirming information.

Requirements:

  1. Working knowledge of GIH claims processes and systems.
  2. You should enjoy working in a team of high performers, who hold each other accountable to perform to their very best.
  3. Experience of fraud investigation strongly desired.
  4. Minimum of 2 years of health insurance or health care provider experience.
  5. Knowledge of claims coding, regulatory rules and medical policy.
  6. Medical/paramedical qualification is a definite plus.
  7. Critical mindset with ability to identify cost containment opportunities.
  8. Experience with data analytics tool(s) is a strong asset.
  9. Excellent verbal and written communication, interpersonal and negotiation skills.
  10. Ability to balance multiple priorities at once and deliver on tight timelines.
  11. Flexibility to work with global teams and varying time zones effectively.
  12. Confidence to deal with internal stakeholders and ability to work with a cross-functional team.
  13. Strong organization skills with the ability to juggle priorities and work under pressure to meet tight deadlines.
  14. Fluency in foreign languages in addition to fluent English is a strong plus.

The estimated salary for this role is around $70,000 - $110,000 per year, depending on location and experience.



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