Fraud Investigation Manager

• Lead the Member Investigation Team who are responsible for identifying and preventing fraudulent, wasteful and abusive expenses within Cigna’s International Business Market ensuring team targets and KPIs are met.
• Works closely with PI FWA senior management to understand strategy and is responsible for executing departmental plans and priorities.
• Responsible for representing the Payment Integrity function when engaging with external clients and reporting to and informing clients of their fraud risks.
• Accountable for managing internal stakeholder relationships.
• Coach, support and provide appropriate case guidance, to Investigators ensuring compliance with investigation standard operating models.
• Ensure department KPIs are met through effective monitoring and reporting mechanisms; ensure PI savings are tracked and reported accurately.
• Executes strategic initiatives, plans, and goals in alignment with department KPIs and financial targets.
• Effectively use business intelligence and data analytics to monitor PI FWA regional claim patterns and identify opportunities for PI intervention and liaises with the Data & Analytics team to develop FWA rulesets.
• Ensures Payment Integrity processes are in compliance with legal, regulatory and contractual requirements.
• Acts with urgency when there is an elevated risk of fraud against Cigna and its customers and clients.
• Ensures investigative findings are documented and that all communications with clients are fact based and professional.
• Assess work demand against capacity to ensure optimum claim referrals across all referral routes; create solutions, drive execution and ensure timeliness and accuracy of PI claims review process, loss prevention and recovery activity.
• Instils work culture of continuous process improvement, innovation, and quality.
• Oversee departmental personnel matters; evaluating staff performance and conducting performance appraisals for all direct reports. Ensure adherence to company practices and procedures.
• Recommends changes in policy and procedures in order to mitigate risk and participates in projects to improve business protocols.
• Provides input into workforce planning and recruitment activities and addresses resource and operational challenges.
• Working closely with other departments to ensure Payment Integrity activities do not have an unnecessary negative impact on our customers.

• Experience of leading operational teams. You should enjoy working in a team of high performers, who hold each other accountable to perform to their very best
• An accredited counter fraud qualification.
• Minimum of 5 years of health insurance or international health care provider experience.
• Experience of operational risk management, including internal and external risk and compliance reporting.
• Knowledge of claims coding, regulatory rules and medical policy.
• Medical/ paramedical qualification is a definite plus.
• Customer Focus – dedicated to meeting the expectations and requirements of internal and external customers, excellent at building effective relationships and gaining trust and respect.
• Passive knowledge of medical terminology and treatment modalities.
• Critical mind-set with ability to identify cost containment opportunities.
• Strong reporting and analytical skills with ability to create and improve reporting packs and methodologies with some support.
• An 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.

Cigna