Fraud Analyst

1 month ago

Nairobi, Nairobi Area, Kenya Cigna Full time

Cigna is a global health service company, dedicated to helping the people we serve improve their health, well-being and sense of security.

Cigna has almost 40,000 employees who service over 80 million customer relationships around the world

Role Summary:
As Fraud Analyst within Payment Integrity Team you will be directly supporting Cigna's affordability commitment within Cigna International's business.

This role is responsible for detecting and recovering FWA payments, creating solutions to prevent claims overpayment and future spend monitoring within a dedicated region.

Will work closely with other Payment Integrity team members, Network, Data & Analytics, Claims Operations, Clinical partners, Product and Member Investigation Unit (MIU).


Responsibilities:

Identify and investigate potential instances of fraud, waste or abuse (FWA) across all Cigna's International Markets books of business for claims incurred in a dedicated region (Middle East & Africa).

Seek recovery of FWA payments from claim submissions.
Ensure PI 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.

Negotiation with providers contracted by Cigna or out-of-Network providers.
Perform data-mining to reveal FWA trends and patterns.
Collaborate with the Special Investigation Unit on Fraud cases.
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.

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 investigation within payment integrity or similar discipline.
Minimum of 4 years of health insurance or health care provider experience.
Knowledge of International Health claim platforms essential.
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
Demonstrated strong organization skills.
Strong attention to detail.
Ability to quickly learn new and complex tasks and concepts.
Excellent verbal and written communication skills.
Ability to balance multiple priorities at once and deliver on tight timelines.
Flexibility to work with global teams and varying time zones effectively.
Experience in liaising with internal stakeholders and ability to work independently within 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

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