Healthcare Fraud Investigator - Case Development- Remote
The job profile for this position is Fraud Lead Analyst, which is a Band 3 Senior Contributor Career Track Role.
Excited to grow your career?
We value our talented employees, and whenever possible strive to help one of our associates grow professionally before recruiting new talent to our open positions. If you think the open position you see is right for you, we encourage you to apply!
Our people make all the difference in our success.
Join a specialized Special Investigations (SIU) referral and case enhancement team focused on identifying and mitigating healthcare fraud. In this role, youâll use your investigative experience and dataâdriven insights to assess suspected fraud referrals, uncover highârisk billing patterns, and guide meaningful investigations that protect patients and reduce financial risk for clients and customers.
Responsibilities:
Independently research, analyze, and assess suspected healthcare fraud referrals using investigative techniques and data analysis.
Identify highârisk billing behaviors, fraud trends, and potential overpayments through detailed data review.
Evaluate referrals submitted to SIU and determine whether allegations warrant full investigation.
Deliver clear, wellâstructured case assessments with actionable investigative recommendations.
Partner closely with investigators and field staff to develop leads and refine investigative strategies.
Use technology and analytics to support complex investigations and adapt investigative direction as new information emerges.
Monitor industry alerts, regulatory updates, and fraud bulletins to assess potential exposure.
Handle sensitive and confidential information with integrity and professionalism.
Qualifications:
Required
3 + years of experience in healthcare insurance investigation, audit or relevant experience
Strong analytical, research, and problemâsolving skills
Clear and concise written and verbal communication skills
Proficiency with Microsoft Excel and Word
Preferred:
Bachelorâs degree in Criminal Justice or related field
AHFI and/or CFE certification
CPT and ICDâ10 coding knowledge
Experience working with data analytics tools and investigative databases
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, youâll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, youâll 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 and paid holidays. For more details on our employee benefits programs, click here.
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.Please note that you must meet our posting guidelines to be eligible for consideration. Policy can be reviewed at this link.
Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.
Apply To This Job
Excited to grow your career?
We value our talented employees, and whenever possible strive to help one of our associates grow professionally before recruiting new talent to our open positions. If you think the open position you see is right for you, we encourage you to apply!
Our people make all the difference in our success.
Join a specialized Special Investigations (SIU) referral and case enhancement team focused on identifying and mitigating healthcare fraud. In this role, youâll use your investigative experience and dataâdriven insights to assess suspected fraud referrals, uncover highârisk billing patterns, and guide meaningful investigations that protect patients and reduce financial risk for clients and customers.
Responsibilities:
Independently research, analyze, and assess suspected healthcare fraud referrals using investigative techniques and data analysis.
Identify highârisk billing behaviors, fraud trends, and potential overpayments through detailed data review.
Evaluate referrals submitted to SIU and determine whether allegations warrant full investigation.
Deliver clear, wellâstructured case assessments with actionable investigative recommendations.
Partner closely with investigators and field staff to develop leads and refine investigative strategies.
Use technology and analytics to support complex investigations and adapt investigative direction as new information emerges.
Monitor industry alerts, regulatory updates, and fraud bulletins to assess potential exposure.
Handle sensitive and confidential information with integrity and professionalism.
Qualifications:
Required
3 + years of experience in healthcare insurance investigation, audit or relevant experience
Strong analytical, research, and problemâsolving skills
Clear and concise written and verbal communication skills
Proficiency with Microsoft Excel and Word
Preferred:
Bachelorâs degree in Criminal Justice or related field
AHFI and/or CFE certification
CPT and ICDâ10 coding knowledge
Experience working with data analytics tools and investigative databases
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, youâll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, youâll 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 and paid holidays. For more details on our employee benefits programs, click here.
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.Please note that you must meet our posting guidelines to be eligible for consideration. Policy can be reviewed at this link.
Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.
Apply To This Job