Fraud Investigator - Special Investigations UnitJoin our Special Investigations Unit (SIU) as a
Healthcare Fraud Investigator, supporting our U.S. Commercial Healthcare business. In this role, you will conduct and support investigations and audits involving potentially fraudulent healthcare claim activity by providers and other parties.
You will use investigative, analytical, and claims-auditing expertise to identify potential fraud, analyze complex information, document findings, and recommend appropriate corrective actions. Depending on investigative findings, recommendations may include recovery, referral for prosecution, litigation, or other actions.
Key Responsibilities:- Conduct and support investigations and audits involving suspected healthcare fraud and potentially fraudulent claim activity.
- Analyze claims, investigative findings, audit results, and other relevant information to identify patterns, discrepancies, and potential fraud.
- Prepare clear written investigative summaries, findings, and recommendations.
- Develop evidence packages for referral to third parties, including contract holders, state insurance fraud bureaus, and law enforcement agencies.
- Lead on-site inspections and conduct patient and provider interviews, as needed.
- Respond to subpoenas and information requests from law enforcement agencies and state Departments of Insurance.
- Represent the company as a witness in judicial proceedings, when appropriate.
- Support special projects requiring expertise in fraud detection, healthcare investigations, claims auditing, and other SIU-related activities.
- Prepare reports and documentation to support effective tracking and reporting of investigations.
Minimum Qualifications:- 3+ years of experience in health insurance investigations and/or auditing.
- Strong investigative and analytical skills with the ability to evaluate information and clearly document findings.
- Excellent verbal and written communication skills.
- Proficiency with Microsoft Excel, Access, and Word.
Preferred Qualifications:- Bachelor's degree in Criminal Justice or a related field.
- Accredited Health Care Fraud Investigator (AHFI) certification or Certified Fraud Examiner (CFE) credential.
- Experience working with healthcare claims, provider investigations, fraud detection, or Special Investigations Units.
If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.
For this position, we anticipate offering an annual salary of 68,300 - 113,900 USD / yearly, depending on relevant factors, including experience and geographic location.
This role is also anticipated to be eligible to participate in an annual bonus plan.
At The Cigna Group, you'll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you'll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k), company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year, paid holidays, and leaves of absence. For more details on our employee benefits programs, click here.
