Fraud Senior Supervisor

This position is a Band 3 Management Career Track Role.

Role Summary

As a Fraud Senior Supervisor within the Member Investigation Unit you will be directly supporting Cigna’s affordability commitment within Cigna International's business and have specific responsibility for the quality and effectiveness of investigations into suspected member behaviours. This role is responsible for managing a team accountable for detecting and recovering FWA payments, creating solutions to prevent claims overpayment and future spend monitoring. This role will partner with internal stakeholders and specifically Client Management Teams to demonstrate good practice anti-fraud services, compliance with global regulatory and legislative requirements and will maintain integrity of all investigative data and reports. He/ She will work closely with other PI team members, Medical Economics, Data & Analytics, Claims Operations, Clinical partners and Product.

Responsibilities

• 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.