Fraud Analyst

The job profile for this position is Fraud Analyst, which is a Band 2 Senior Contributor Career Track Role.

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Role Summary:

As Fraud Analyst within Payment Integrity Team you will be directly supporting Cigna’s affordability commitment within Cigna International's business. This role is responsible for 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). He/She will work closely with other PI team members, Network, Data & Analytics, Claims Operations, Clinical partners, Product and Member Investigation Unit (MIU).

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.
• Negotiation 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.
• Work with team members and manager to develop FWA cases

Skills and Requirements:

• Working knowledge of GIH claims processes and systems
• You should enjoy working in a team of high performers, who hold each other accountable to perform to their very best.
• Experience of fraud investigation strongly desired.
• Minimum of 2 years of health insurance or health care provider experience.
• Knowledge of claims coding, regulatory rules and medical policy.
• Medical/ paramedical qualification is a definite plus.
• Critical mind-set 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.
• Fluency in foreign languages in addition to fluent English is a strong plus.
• Hybrid work location