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Healthcare Fraud Investigator - Express Scripts, St. Louis, Missouri

Job typeFull Time
CountryUnited States
CitySt. Louis

The Fraud Investigator is responsible for customer/patient investigations and presentation of fraud and/or abuse cases. Using analytical skills, in-depth drug and medical expertise, the investigator will independently develop and execute investigation plans to formalize sound in-depth referrals to law enforcement, commercial and government health plans to mitigate future fraud risk.

  • Perform desk investigations on members and beneficiaries to look for fraud, waste or abuse.
  • Performance of investigations includes obtaining, analyzing, and appraising evidentiary data on which to base an informed, objective opinion on the legitimacy of claims audited.
  • Communication and coordination with appropriate agencies.
  • Manage case workload by utilizing all available resources, effectively prioritizing/planning/scheduling and accounting for work, maintaining the tracking data base, providing management information as requested.
  • Recognizes evidence and determines its value to specific claims and the overall investigation, evidence collection and interpretation for investigations.
  • Utilize existing tools, including Access, Excel, SQL, etc., while utilizing personal knowledge of medications to identify prescribing claims history representing network wide risks.
  • Develop an investigative plan, using appropriate investigational techniques, to address those risks efficiently and effectively.
  • Prepare formal referrals for management, commercial clients and government clients.
  • Perform special projects as assigned.

  • College degree or equivalent work experience
  • 4-7 years of relevant experience investigating healthcare fraud, serving as a pharmacy technician, a health care professional, or data analyst.
  • Nurse, Certified Pharmacy Technician, Accredited Health Care Fraud Investigator, Certified Fraud Examiner, or similar certification preferred.
  • Highly proficient in data warehousing, database and spreadsheet applications (Excel, Access, SQL).
  • Excellent organizational and interpersonal skills; critical thinking and planning skills, verbal and written communication skills.

This role is Flex/WFH which allows most work to be performed at home or on occasion at a Cigna office location. Employees must be fully vaccinated if they choose to come onsite.

About Cigna

Cigna Corporation exists to improve lives. We are a global health service company dedicated to improving the health, well-being and peace of mind of those we serve. Together, with colleagues around the world, we aspire to transform health services, making them more affordable and accessible to millions. Through our unmatched expertise, bold action, fresh ideas and an unwavering commitment to patient-centered care, we are a force of health services innovation. When you work with us, or one of our subsidiaries, you'll enjoy meaningful career experiences that enrich people's lives. What difference will you make?

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.
Employer187 Express Scripts Services Co