POSITION SUMMARY

The Fraud Investigator role is responsible for the development, investigation, and presentation of complex fraud and/or abuse cases. Using analytical skills, in-depth drug and medical expertise, and audit tools in order to independently develop and execute an investigation. A substantiated case, subject to certain criteria, will result in an in-depth referral to impacted clients.

ESSENTIAL FUNCTIONS

• Perform fraud, waste, and abuse virtual investigations of members identified with potential risk associated with their prescription benefit


• Conduct data analytics, research industry trends, prepare documents and reports that pertain to investigative findings and research.


• Lead virtual interviews of member/providers and pharmacies as necessary to obtain information regarding the investigation


• Performance of investigations includes: Obtaining, analyzing, and appraising evidentiary data on which to base an informed, objective opinion on the legitimacy of investigated claims. Effectively communicate investigative findings in professionally written format to plan sponsors and Government agencies with actionable information to manage and mitigate fraud, waste, and abuse.

QUALIFICATIONS

• Clear and concise verbal and written communication skills


• Strong computer skills are required - Excel, Access and Word


• Bachelor's Degree and/or 1-3 years of relevant pharmacy benefit management, pharmacy technician or medical/insurance auditing or investigating experience in lieu of degree

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.

About Evernorth Health Services

Evernorth Health Services, a division of The Cigna Group, creates pharmacy, care and benefit solutions to improve health and increase vitality. We relentlessly innovate to make the prediction, prevention and treatment of illness and disease more accessible to millions of people. 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: SeeYourself@cigna.com for support. Do not email SeeYourself@cigna.com for an update on your application or to provide your resume as you will not receive a response.

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.