Description
We are seeking an exceptional leader to build and advance the Payment Integrity and Investigations capability across Cigna International Health.
The Director will define the strategic vision, operating model and future roadmap for Payment Integrity, bringing together data, analytics, clinical expertise, investigations and technology to identify risk, prevent leakage and deliver sustainable outcomes.
Key Accountabilities
- Payment Integrity Strategy & Operating Model
- Own and execute the international Payment Integrity and Investigations strategy, aligning priorities with affordability objectives, business needs, regulatory requirements and enterprise capabilities.
- Design and continuously evolve an integrated operating model spanning pre-payment controls, post-payment review, analytics, investigations, clinical and coding audit, recovery and root-cause remediation.
- Establish a multi-year capability roadmap covering people, process, data, technology, governance and external partnerships, with clear investment priorities and measurable outcomes.
- Pre-Payment Prevention & Post-Payment Review
- Lead the development and optimization of pre-payment edits, clinical rules, coding validations, duplicate-payment controls, tariff and contract checks and other interventions that prevent leakage before payment.
- Oversee post-payment analytics, targeted audits, claim reviews and data-mining activities to identify inappropriate payments, emerging patterns and recovery opportunities.
- Investigations, Fraud, Waste & Abuse
- Lead the Special Investigations capability for suspected fraud, waste, abuse and error involving providers, members, intermediaries or other relevant parties.
- Establish risk-based case intake, triage, investigation, evidence, referral and closure standards that support consistent, timely and defensible outcomes.
- Recovery, Value Delivery & Performance Management
- Own the financial and operational performance of the function, including prevention, cost avoidance, identified savings, validated savings, recoveries, productivity, quality, cycle times and return on investment.
- Build a disciplined recovery strategy across providers, members, vendors and third parties while balancing financial value, contractual rights, provider relationships and customer experience.
- Data, Analytics & Technology Enablement
- Define the data and analytics strategy for Payment Integrity and Investigations, including data quality, governance, model performance and actionable insight generation.
- Sponsor advanced analytics, machine learning, artificial intelligence and automation initiatives that improve detection, prioritization, investigator effectiveness and case conversion.
- Governance, Compliance & Quality Assurance
- Establish an effective anti-fraud and payment integrity governance framework, including policies, procedures, controls, evidence requirements and oversight forums.
- Ensure investigations, audits, data usage, recoveries and external disclosures comply with applicable legal, regulatory, privacy and records-management requirements.
- Leadership, Partnerships & Commercial Enablement
- Lead, develop and inspire a global multidisciplinary team spanning clinical, coding, audit, analytics, investigations, operations and recovery expertise.
- Foster a high-performance culture focused on integrity, accountability, innovation, collaboration and measurable outcomes.
Requirements & Qualifications
- 15+ years of progressive experience in healthcare payment integrity, claims, special investigations, fraud risk, clinical audit, healthcare finance or related operations, including significant leadership responsibility.
- Proven success leading complex, multidisciplinary teams and delivering measurable payment prevention, savings, recovery, quality and operational outcomes.
- Strong knowledge of healthcare claims, reimbursement, coding, provider billing, clinical review, investigative methods, fraud, waste and abuse risks and recovery practices.
- Demonstrated ability to design and implement operating models, governance frameworks, controls, analytics and technology-enabled transformation across multiple markets or business lines.
What We Offer
- A rare opportunity to build, lead and transform a critical capability within Cigna International Health.
- The platform to set the strategic direction for Payment Integrity and Investigations across international markets.
- Measurable impact on healthcare affordability, financial integrity and customer trust.
- Enterprise-wide transformation through data, analytics, AI and operational innovation.
- Influence senior leadership decision-making and shape long-term business strategy.
- A highly competitive compensation package and the opportunity to grow your career within a global healthcare leader.