About this opportunity
Original employer descriptionAbout Cigna Healthcare
At Cigna Healthcare, we are committed to improving the health, well-being and peace of mind of those we serve. As part of The Cigna Group, we support millions of customers worldwide through innovative healthcare solutions, global expertise and a relentless focus on delivering sustainable, high-quality care.
Within Cigna International Health, we help individuals, families and organizations navigate healthcare across borders, combining clinical excellence, digital innovation and operational expertise to create exceptional experiences for our customers and partners around the world.
We are looking for leaders who share our passion for transforming healthcare, driving meaningful impact and delivering better outcomes for customers, clients and providers.
Position Summary
We are seeking an exceptional leader to build and advance the Payment Integrity and Investigations capability across Cigna International Health.
Reporting into senior leadership, this role is accountable for protecting healthcare affordability, strengthening payment accuracy, preventing fraud, waste and abuse, and driving measurable financial and operational value across international markets.
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. This is a highly visible leadership position that offers the opportunity to influence enterprise-wide decisions, partner with senior executives and shape one of the most critical affordability capabilities within Cigna International Health.
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.
- Define consistent standards, decision rights, escalation pathways and service expectations across global and regional teams while enabling appropriate local market execution.
- Position Payment Integrity as a strategic affordability, risk management and value-creation capability supporting sustainable growth and a differentiated client proposition.
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.
- Ensure payment integrity concepts are evidence-based, operationally executable and supported by robust testing, documentation and change management processes.
- Partner with Claims, Provider Operations, Network, Clinical, Pharmacy, Data, Technology, Partnerships and Controls teams to embed effective controls into end-to-end workflows.
- Drive root-cause analysis and sustainable remediation so identified issues result in improved upstream processes, policies, provider arrangements and system controls.
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.
- Develop proactive detection models, intelligence-led investigations, provider profiling and network surveillance to identify complex or organized patterns of inappropriate activity.
- Partner closely with Compliance, Legal, Privacy, Security, Human Resources and external authorities on sensitive cases, regulatory notifications, sanctions and law enforcement referrals where appropriate.
- Maintain clear separation between allegation, investigation and substantiated findings, ensuring fairness, confidentiality and procedural integrity throughout the case lifecycle.
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.
- Establish transparent management information, forecasting, benefit validation and reporting standards that provide leadership with a reliable view of performance, risks and delivery confidence.
- Prioritize initiatives and investigations based on value, risk, complexity, likelihood of recovery, regulatory exposure and strategic importance.
- Ensure savings methodologies are consistent, auditable and aligned with Finance and business stakeholders.
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.
- Partner with Data, Technology and Medical Economics teams to improve claims, clinical, provider, tariff, contract and payment data quality across markets and platforms.
- Implement appropriate model governance, human oversight, testing, monitoring and explainability for AI-enabled decision support tools.
- Leverage internal and external intelligence sources to identify emerging fraud schemes, market-specific risks and new control opportunities.
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.
- Implement quality assurance, peer review, case sampling and audit-readiness practices across operational and investigative activities.
- Maintain strong controls around conflicts of interest, confidentiality, access management and segregation of duties.
- Provide timely reporting of material risks, control weaknesses, trends and remediation plans to senior leadership and governance bodies.
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.
- Build strong relationships with regional business leaders, TPAs, vendors, providers, Cigna Links and enterprise functions.
- Translate Payment Integrity and Investigations capabilities into compelling client-facing value propositions supporting RFPs, renewals and retention efforts.
- Represent the function with executive leadership, clients, providers, auditors, regulators and external partners as required.
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.
- Sound understanding of compliance, privacy, evidence handling, regulatory engagement and legal considerations relevant to investigations and payment recovery.
- Excellent analytical judgement, executive communication and stakeholder management skills.
- Proven ability to influence senior leaders and drive change across matrixed international organizations.
- Bachelor's degree in Healthcare Administration, Business, Finance, Clinical Sciences, Data Analytics, Law, Criminal or Forensic Justice or a related field required.
- Advanced degree and/or relevant professional certification preferred.
- International experience and willingness to travel as required.
- Additional language capabilities are an advantage.
What We Offer
This role offers a rare opportunity to build, lead and transform a critical capability within Cigna International Health.
You will have the platform to:
- Set the strategic direction for Payment Integrity and Investigations across international markets.
- Deliver measurable impact on healthcare affordability, financial integrity and customer trust.
- Lead enterprise-wide transformation through data, analytics, AI and operational innovation.
- Influence senior leadership decision-making and shape long-term business strategy.
- Build a lasting legacy by developing a modern, scalable and market-leading Payment Integrity function.
- Collaborate with talented colleagues across clinical, claims, provider, finance, compliance and technology disciplines globally.
- Be rewarded with a highly competitive compensation package and the opportunity to grow your career within a global healthcare leader.
About Cigna Healthcare
Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. 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.
