Financial Crime Investigator
hace 1 semana
About Cigna Healthcare
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 healthcare system, empowering them with the information and insight they need to make the best choices for improving their health and vitality.
Estimated Salary Range: $85,000 - $110,000 per year, depending on location and experience.
Job Description:
We are seeking a skilled Fraud Analyst to join our Payment Integrity Team. As a key member of our team, you will be responsible for detecting and recovering fraudulent payments, creating solutions to prevent claims overpayment, and conducting spend monitoring within a dedicated region (Americas geography).
You will work closely with other PI team members, Network, Data & Analytics, Claims Operations, Clinical partners, Product, and Member Investigation Unit (MIU) to achieve our affordability commitment within Cigna International's business.
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 along side senior investigators.
- Adhere to turn-around times and timelines on investigations.
- Contact providers and members requesting documents and confirming information.
Required Skills and Qualifications:
- Working knowledge of GIH claims processes and systems.
- A minimum of 2 years of health insurance or healthcare provider experience.
- Experience of fraud investigation strongly desired.
- Knowledge of claims coding, regulatory rules, and medical policy.
- Mechanical/paramedical qualification is a definite plus.
About Us:
We value our talented employees and strive to help one of our associates grow professionally before recruiting new talent to our open positions. If you think this role is right for you, we encourage you to apply.
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