Healthcare Fraud Investigator (Remote)

Fraud Investigator – Special Investigations Unit

Join 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.

About The Cigna Group

Doing something meaningful starts with a simple decision, a commitment to changing lives. At The Cigna Group, we’re dedicated to improving the health and vitality of those we serve. Through our divisions Cigna Healthcare and Evernorth Health Services, we are committed to enhancing the lives of our clients, customers and patients. 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 need a reasonable accommodation to complete the online application process, please email seeyourself@thecignagroup.com for assistance.  Please note that this email inbox is dedicated to accommodation requests only and cannot provide application updates or accept resumes.

The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.

Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.