Fraud Analyst –Payment Integrity Member Investigation Unit

at  The Cigna Group

FRAUD ANALYST –PAYMENT INTEGRITY MEMBER INVESTIGATION UNIT

The job profile for this position is Fraud Analyst –Payment Integrity Member Investigation Unit (MIU), which is a Band 2 Senior Contributor Career Track Role.

SKILLS AND REQUIREMENTS:

• 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 within Healthcare or similar discipline strongly desired.
• Minimum of 2 years of health insurance claims experience 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 is a strong asset.
• Strong attention to detail.
• Excellent verbal and written communication skills.
• Flexibility to work with global teams and varying time zones effectively.
• Confidence to liaise with internal stakeholders.
• Strong organization skills with the ability to juggle priorities and work under pressure to meet tight deadlines.
• Experience of full Microsoft suite.
• Fluency in foreign languages in addition to fluent English is a strong plus.

ROLE SUMMARY:

As Fraud Analyst within the Member Investigation Unit (MIU) you will be directly supporting Cigna’s affordability commitment within Cigna International’s business. This role is responsible for detecting and recovering fraudulent, waste or abusive (FWA) payments, creating solutions to prevent claims overpayment and future spend monitoring. He/She will work closely with other Payment Integrity (PI) team members, Network, Medical Economics, Data Analytics, Claims Operations, Clinical partners and Product.

RESPONSIBILITIES:

• Identify and Investigate potential instances of fraud, waste or abuse (FWA) across all Cigna’s International Markets books of business for claims incurred.
• Seek recovery of FWA payments from claim submissions.
• Ensure savings are tracked and reported accurately.
• Work in partnership to implement solutions and drive execution to prevent claims overpayment, unnecessary claim spend, and ensure timeliness and accuracy of PI claims review process.
• Perform data-mining to reveal FWA trends and patterns.
• Partner with Cigna TPAs on FWA 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.
• Provide investigation reports to internal and external stakeholders.