Fraud Senior Advisor

Cigna Healthcare•St. Louis, MO

About The Position

Job Summary The Sr. Fraud Advisor within eFWA Services is responsible for delivering expert fraud prevention and compliance support to clients, ensuring adherence to regulatory standards, and driving operational excellence. This role involves managing audits, client consultations, reporting, and compliance activities while serving as a trusted advisor on fraud-related matters. The Sr. Fraud Advisor will collaborate with internal teams and external stakeholders to mitigate fraud risks, maintain compliance, and enhance client satisfaction. Key Responsibilities Client Consultation: Serve as the primary point of contact for client inquiries and consultations; conduct quarterly client consultation sessions; provide strategic guidance on fraud prevention and compliance requirements. Audits: Perform client audits to ensure contractual and regulatory compliance; conduct internal audits; support CMS audits and maintain tracer documentation for audit readiness. Client Reporting: Prepare and deliver quarterly reports to clients; complete Excellus reports by the 10th of each month; ensure timely and accurate reporting aligned with client expectations. Field Alerts: Issue monthly commercial alerts by the 15th; coordinate SAM COM notifications; prepare quarterly outlier reports for Medicare Part D within 45 days of CMS data availability announcements. Compliance & Policy Meetings: Participate in compliance and policy meetings; provide fraud-related insights and recommendations. Industry Engagement: Represent the organization on Health Care Fraud Shield monthly calls to stay informed on emerging fraud trends and tools. Operational Performance: Maintain and update the Operations Workbook with performance data; monitor KPIs and identify areas for improvement. Requests for Information (RFI): Manage Medicare-specific RFIs; ensure timely and accurate responses. Requests for Proposal (RFP): Support RFP development and submission processes for fraud-related services. Ad-Hoc Client Requests: Respond to high-volume ad-hoc client questions and project requests; provide timely, accurate, and actionable solutions. Qualifications Education: Bachelor’s degree in Healthcare Administration, Business, Criminal Justice, or related field (Master’s preferred). Experience: Minimum 5+ years in healthcare fraud prevention, compliance, or auditing; experience with CMS audits, Medicare/Medicaid programs, and regulatory reporting. Certifications: Certified Fraud Examiner (CFE), Certified Professional Coder (CPC), or similar preferred. Technical Skills: Proficiency in Microsoft Excel, reporting tools, and audit documentation systems; familiarity with Health Care Fraud Shield and related platforms. Core Skills Strong analytical and investigative skills. Excellent communication and client relationship management. Ability to manage multiple priorities in a fast-paced environment. Detail-oriented with a commitment to accuracy and compliance. Problem-solving and critical thinking capabilities. Collaborative mindset with cross-functional teams. Company Culture Our culture is built on collaboration, inclusivity, and continuous improvement. We believe that success comes from working together across boundaries and fostering an environment where every voice matters. Employees are encouraged to share ideas, learn from challenges, and embrace innovation. We prioritize belonging and engagement, knowing that when people feel connected, they thrive. Our ethos emphasizes honesty, trust, and transparency, ensuring that integrity guides every decision. We celebrate diversity, encourage growth, and create opportunities for employees to do extraordinary things while enjoying their work. 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 The Cigna Group Doing something meaningful starts with a simple decision, a commitment to changing lives. At The Cigna Group, we’re dedicated to improving the health and vitality of those we serve. Through our divisions Cigna Healthcare and Evernorth Health Services, we are committed to enhancing the lives of our clients, customers and patients. 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: [email protected] for support. Do not email [email protected] 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. Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances. Doing something meaningful starts with a simple decision, a commitment to changing lives. At The Cigna Group, we’re dedicated to improving the health and vitality of those we serve. Through our divisions Cigna Healthcare and Evernorth Health Services, we are committed to enhancing the lives of our clients, customers and patients. Join us in driving growth and improving lives.

Requirements

Bachelor’s degree in Healthcare Administration, Business, Criminal Justice, or related field (Master’s preferred)
Minimum 5+ years in healthcare fraud prevention, compliance, or auditing
Experience with CMS audits, Medicare/Medicaid programs, and regulatory reporting
Strong analytical and investigative skills
Excellent communication and client relationship management
Ability to manage multiple priorities in a fast-paced environment
Detail-oriented with a commitment to accuracy and compliance
Problem-solving and critical thinking capabilities
Collaborative mindset with cross-functional teams
Proficiency in Microsoft Excel, reporting tools, and audit documentation systems
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

Nice To Haves

Master’s preferred
Certified Fraud Examiner (CFE), Certified Professional Coder (CPC), or similar preferred
Familiarity with Health Care Fraud Shield and related platforms

Responsibilities

Serve as the primary point of contact for client inquiries and consultations
Conduct quarterly client consultation sessions
Provide strategic guidance on fraud prevention and compliance requirements
Perform client audits to ensure contractual and regulatory compliance
Conduct internal audits
Support CMS audits and maintain tracer documentation for audit readiness
Prepare and deliver quarterly reports to clients
Complete Excellus reports by the 10th of each month
Ensure timely and accurate reporting aligned with client expectations
Issue monthly commercial alerts by the 15th
Coordinate SAM COM notifications
Prepare quarterly outlier reports for Medicare Part D within 45 days of CMS data availability announcements
Participate in compliance and policy meetings
Provide fraud-related insights and recommendations
Represent the organization on Health Care Fraud Shield monthly calls to stay informed on emerging fraud trends and tools
Maintain and update the Operations Workbook with performance data
Monitor KPIs and identify areas for improvement
Manage Medicare-specific RFIs
Ensure timely and accurate responses
Support RFP development and submission processes for fraud-related services
Respond to high-volume ad-hoc client questions and project requests
Provide timely, accurate, and actionable solutions