Fraud Senior Analyst –Payment Integrity Provider Investigation APAC Team

Job Purpose

The Fraud Senior Analyst plays a critical role in protecting the organization’s International Health portfolio by leading Fraud, Waste and Abuse (FWA) investigations, driving measurable affordability outcomes, and strengthening prevention strategies across the claims lifecycle. The position combines investigative expertise, data-driven insight, and stakeholder influence to reduce financial leakage, improve claim governance and support sustainable savings delivery across the region. This role is responsible for detecting and recovering FWA payments, creating solutions to prevent claims overpayment and future spend monitoring within a dedicated region. He / She will work closely with other PI team members, Network, Medical Economics, Data Analytics, Claims Operations, Clinical partners, and Product.

Job Profile

Operating with a high degree of independence, the Fraud Senior Analyst owns end-to-end investigative activities within a dedicated region. The role extends beyond case handling to include proactive identification of systemic risks, development of preventive controls, and partnership with regional and global stakeholders to enhance Payment Integrity strategy. The incumbent acts as a subject matter expert, contributing to operational improvements, automation initiatives, and cross-market collaboration to strengthen FWA detection and mitigation capabilities.

Reports to:  Fraud Manager      

Critical Tasks and Expected Contributions / Results:

• Lead FWA investigations across International Markets, applying investigative judgement to identify billing anomalies, emerging fraud typologies, and systemic risk patterns.

• Deliver quantifiable financial impact through cost containment, recoveries, and forward-looking prevention initiatives aligned to regional savings objectives.

• Translate data insights into actionable investigation strategies by partnering closely with Data and Analytics teams to refine triggers, reporting frameworks and automation opportunities.

• Influence provider behavior through structured Provider audit engagement, negotiation, and collaboration with regional and global stakeholders to reduce future risk exposure.

• Drive continuous improvement of Payment Integrity processes by identifying operational gaps and proposing scalable solutions that enhance efficiency and accuracy.

• Produce clear, defensible investigative findings and recommendations for senior stakeholders, ensuring transparency and audit readiness.

• Ensure investigations and cost containment actions are balanced with fair member outcomes, regulatory expectations, and client commitments.

• Collaborate with Customer Service and Client Management teams to support clear, consistent communication approaches that protect member experience while maintaining investigative integrity

• Operate within established governance frameworks, ensuring investigative activities are compliant with internal policies, regulatory requirements, and audit standards.

• Collaborate with the Member Investigation Unit on Fraud cases when required.

• Perform periodic TPA oversight and partner with TPAs on FWA investigations when required.

• Partner with Data Analytics team in building future FWA triggers automation.

• Mentor and provide support  through knowledge sharing, quality review input and guidance on investigative best practices and share FWA claiming schemes.

• Ad hoc duties as assigned

Key Challenges / Anticipated Changes in Environment:

• Rapid evolution of provider billing models and fraud schemes requiring adaptive investigative approaches.

• Increasing claim volumes and evolving FWA typologies requiring advanced analytical and investigative skills

• Balancing operational turnaround times with deep investigative rigor, stakeholder expectations and member experience considerations

• Expanding use of automation, data analytics, and cross-market collaboration within Payment Integrity operations

• Managing complex provider relationships while maintaining firm compliance and cost containment positions

• Navigating diverse regulatory and healthcare environments across multiple international markets

Developmental Value of Position:

• Strengthens strategic thinking through ownership of regional investigative portfolios and measurable savings delivery.

• Builds advanced expertise in international health insurance investigations, audit frameworks, and provider engagement strategies

• Develops leadership capabilities through ownership of complex cases, cross-functional collaboration, and influence without direct people management

• Provides exposure to advanced analytics initiatives, provider strategy discussions and global Payment Integrity frameworks

• Opportunity to deepen technical knowledge in healthcare claims coding, regulatory consideration and fraud risk management

Experience/Knowledge, Education and Other 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 Mainframe, GlobalCare, Actisure and / or Diamond 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.

About The Cigna Group