Fraud Senior Advisor

The Cigna Group•St. Louis, MO

About The Position

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.

Requirements

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.
Technical Skills: Proficiency in Microsoft Excel, reporting tools, and audit documentation systems; familiarity with Health Care Fraud Shield and related platforms.
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.

Nice To Haves

Certified Fraud Examiner (CFE), Certified Professional Coder (CPC), or similar preferred.

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.