Healthcare Fraud Investigator - Case Development- Remote
Join a specialized Special Investigations (SIU) referral and case enhancement team focused on identifying and mitigating healthcare fraud. In this role, you'll use your investigative experience and data-driven insights to assess suspected fraud referrals, uncover high-risk 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 high-risk 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, well-structured 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 problem-solving skills
- Clear and concise written and verbal communication skills
- Proficiency with Microsoft Excel and Word
Preferred:
- Bachelor's degree in Criminal Justice or related field
- AHFI and/or CFE certification
- CPT and ICD-10 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, you'll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you'll 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. Apply To this Job