Fraud Manager – Payment Integrity

Fraud Manager – Payment Integrity

The job profile for this position is Fraud Manager, which is a Band 4 Management Career Track Role.

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Role Summary:

As a Fraud Manager within the Payment Integrity (PI) Team you will be directly supporting Cigna’s affordability commitment within Cigna International's business and have specific accountability for the quality and effectiveness of investigations into suspected fraudulent or abusive behaviors. This role will partner closely with the Clients and Client Management Teams to influence and implement initiatives and programs designed to stop, prevent and recover fraud and abusive overpayments.

This role is responsible for leading remote, investigative teams who are responsible for identifying, preventing and recovering fraudulent, wasteful and abusive expenses within Cigna’s International Business Market. The post holder will lead teams to develop and execute solutions to identify and prevent claims overpayments through FWA schemes. As an experienced professional and role model, you will direct your team to coordinate a variety of pre and post-pay focused loss prevention activities. He/ She will work closely with the Regional PI teams, Client Management, Network, Data & Analytics, Claims Operations, Clinical partners, and Product Teams.

Responsibilities

• Direct Payment Integrity activities, end to end, with respect of Member and Provider fraud risk typologies, including creating and managing cost containment opportunities to achieve affordability targets.
• Apply and transfer FWA industry-knowledge to develop the FWA control environment across new and emerging International Health products.
• Develop strategic intelligence and investigative standards, ensuring adherence to regulatory standards and best practices.
• Identifies cost effective technologies, workflows and vendor partnerships necessary to meet PI strategic commitments.
• Work closely with PI FWA senior management to input into PI strategy and is responsible for executing departmental plans and priorities.
• Drives changes in product, policy, procedures in order to mitigate risk and represent PI FWA in key projects and initiatives across International Markets.
• Engage effectively with internal and external stakeholders to deliver management information and reporting in a timely manner.
• Identify new and emerging fraud schemes and influence the development and delivery of solutions to maximize plan savings for Cigna and its clients.
• Optimize workflows and communication with cross-functional teams, and create robust SOPs and PI metrics.
• Ensure PI processes are in compliance with each legal, regulatory and contractual requirements.
• Coach and support direct reports to perform investigations, reviews, and audits and oversee successful implementation of recommendations to improve the control environment to prevent future fraud occurrences. 
• Effectively use business intelligence and data analytics to monitor PI FWA member claim patterns and identifies opportunities for PI intervention and liaises with the Data & Analytics Product Owner to develop FWA rulesets.
• Ensure department KPIs are met through effective monitoring and reporting mechanisms; ensure PI savings are tracked and reported accurately.
• 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.
• Provides input into workforce planning and recruitment activities and addresses resource and operational challenges. 
• Provides SME guidance to assist law enforcement or Cigna legal teams or their representatives in the pursue to criminal or civil redress following fraud identification against Cigna. 
• Acts with urgency when there is an elevated risk of fraud against Cigna and its customers and clients.
  
  

Skills and Requirements

• Proven track record of leading global and/or remote anti-fraud operational teams within financial services. 
• 10 + years experienced in insurance claim management operations, including at least 3+ years of experience within medical and/or life and pensions required.
• 10+ years expertise in implementing and operating an intelligence capability.
• An accredited counter fraud qualification is desirable.
• Medical/ paramedical qualification is a definite plus.
• Proven experience in influencing and coaching teams to identify and recover overpayments.
• Customer Focus – dedicated to meeting the expectations and requirements of internal and external customers, excellent at building effective relationships and gaining trust and respect.
• Knowledge of fraud typologies, medical terminology and treatment modalities.
• Critical mind-set with ability to identify cost containment opportunities. Effectively use data to inform key decision making and strategic direction (e.g. cost containment, projects and initiatives, staffing forecasts).
• Strong data analytics tool(s) knowledge required.
• 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.
• Strong organization skills with the ability to juggle priorities and work under pressure to meet tight deadlines.
  
  

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 health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. Join us in driving growth and improving lives.

Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.

If you require reasonable accommodation in completing the online application process, please email: SeeYourselfEMEA@cigna.com for support. Do not email SeeYourselfEMEA@cigna.com for an update on your application or to provide your resume as you will not receive a response.<
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