Job Closed

This listing is no longer active.

Fraud Senior Advisor

Financial CrimeFinancial CrimeOtherRemoteSeniorTeam 10,001+Since 1982H1B No SponsorCompany SiteLinkedIn

Location

United States

Posted

101 days ago

Salary

0

Seniority

Senior

No structured requirement data.

Job Description

Fraud Senior Advisor

The Cigna Group

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description 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. 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. Requirements - 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. Benefits - 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. Company Description 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.

Job 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.
  • 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.
  • 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.

Benefits

  • 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.

Related Categories

Related Job Pages

More Financial Crime Jobs

Stripe, Inc. logo

Fraud Strategist

Stripe, Inc.

Stripe, Inc. is a global technology company with offices and remote employees worldwide, team members who speak more than 30 languages, and millions of users. A

Financial Crime101 days ago

Who we are About Stripe Stripe is a financial infrastructure platform for businesses. Millions of companies—from the world’s largest enterprises to the most ambitious startups—use Stripe to accept payments, grow their revenue, and accelerate new business opportunities. Our mission is to increase the GDP of the internet, and we have a staggering amount of work ahead. That means you have an unprecedented opportunity to put the global economy within everyone’s reach while doing the most important work of your career. About the team Stripe’s Fraud Risk Strategy Team is committed to minimizing Stripe’s financial losses from fraud attacks. The Fraud Risk Strategy Team is responsible for building and implementing strategies that scalably reduce risk for Stripe and preserve a healthy financial and payments ecosystem, while creating positive experiences for users. What you’ll do As a Risk Strategist on the Merchant Fraud team, you will be directly responsible for decreasing losses emanating from fraudsters operating on Stripe. You will enable safer payments for our users and help Stripe manage payments risks intelligently. The stakes are high, and you will be up against ever-evolving challenges. You will face some of the most complex and dynamic problems at the company, and the nature of your work will evolve rapidly to combat new and more sophisticated challenges to Stripe’s payments integrity. Responsibilities - Analyze accounts and transactions to identify and predict risky behavior that could result in losses for Stripe or pose challenges to the broader payments ecosystem - Scale risk processes to cover an increasingly large and complex landscape of payments risks and effectively design strategies and solutions that might range from ML model features to manual review workflows - Work with internal partners like Engineering, Product, Data Science and Operations to develop solutions that would mitigate fraud risk across different geographies, payment methods and products - Work with Stripe users to educate them about and help prevent potential risks to their business - Challenge the payments industry status quo to help enable innovative businesses to flourish online Who you are We’re looking for someone who meets the minimum requirements to be considered for the role. If you meet these requirements, you are encouraged to apply. The preferred qualifications are a bonus, not a requirement. Minimum requirements - 8+ years of relevant professional experience - Curiosity and passion for risk prevention: if something seems off, you want to investigate what’s going on and solve root problems - Strong analytical skills - you are passionate about data analysis and can frame business decisions and tradeoffs effectively through quantitative analysis and visualization - Intermediate SQL skills and experience in applying these skills in business environments - Decisiveness, yet open to learning: you will make many critical decisions every day impacting large numbers of merchants - Understanding and empathy for the challenges of setting up a new business - you will thoughtfully balance scaled enforcement decisions with user experience - Excellent communication skills and knows how to be a team player - you are able to convey complex ideas succinctly and work effectively across teams - Project management skills - you have demonstrated project management skills and the ability to drive execution on projects that span multiple teams both within and outside of Risk Preferred qualifications - Expertise with SQL - Expertise with quantitative tools such as Python, R, or Stata - Experience with payments (particularly working with regional payment methods), risk, or trust & safety - Experience working with Engineering, Operations and/or Data Science teams - Experience working in fast-paced and rapidly changing start-up environments

United States + 1 moreAll locations: United States | Canada
Job Closed
Stripe, Inc. logo

Risk Strategist, Financial Crimes Program Integrity – Effectiveness

Stripe, Inc.

Stripe, Inc. is a global technology company with offices and remote employees worldwide, team members who speak more than 30 languages, and millions of users. A

Financial Crime101 days ago

• Lead efforts in either Standards & Enablement or FC Performance • Translate complex regulatory requirements into executable standards • Manage cross-functional incidents • Partner with Engineering to deploy AI-powered investigative solutions • Design high-performance execution frameworks • Continuously strengthen program resilience • Translate emerging threat intelligence into detection enhancements • Design scalable risk frameworks

Illinois
Job Closed
Stripe, Inc. logo

Risk Strategist, Financial Crimes Program Integrity & Effectiveness

Stripe, Inc.

Stripe, Inc. is a global technology company with offices and remote employees worldwide, team members who speak more than 30 languages, and millions of users. A

Financial Crime101 days ago

Who we are About Stripe Stripe is a financial infrastructure platform for businesses. Millions of companies - from the world’s largest enterprises to the most ambitious startups - use Stripe to accept payments, grow their revenue, and accelerate new business opportunities. Our mission is to increase the GDP of the internet, and we have a staggering amount of work ahead. That means you have an unprecedented opportunity to put the global economy within everyone's reach while doing the most important work of your career. About the team The Financial Crimes Program Integrity & Effectiveness (FC PIE) team designs and scales the operating system of Stripe’s Financial Crimes program. We build the standards, execution frameworks, and feedback loops that make investigations and the FC Program faster, smarter, and AI-native. Our focus is driving measurable program effectiveness, investigative velocity, and scalable risk mitigation as Stripe grows. What you’ll do Depending on your expertise, you will lead efforts in either Standards & Enablement (designing and scaling the "how" of investigations to manage risk) or FC Performance (integrating threat and typology insights enabling measurable effectiveness). You will translate complex regulatory requirements into executable standards, manage cross-functional incidents, and partner with Engineering to deploy AI-powered investigative solutions. Responsibilities - Design High-Performance Standards: Translate AML and Sanctions policies into executable standards and design high-performance execution frameworks that scale globally. - Drive Program Performance & Resilience: Continuously strengthen program resilience by identifying systemic gaps, improving control coverage, and embedding sustainable standard enhancements that improve quality and reduce rework. Define and track program health metrics (quality, consistency, escalation rates, cycle time) to proactively identify and resolve structural weaknesses. - Operationalize Intelligence into Detection Lift: Translate emerging threat intelligence into detection enhancements, process adjustments, and measurable risk coverage improvements across investigations and controls. - Optimize Risk-Adjusted Expansion: Design scalable risk frameworks that enable responsible expansion into higher-risk segments by optimizing controls, review strategies, and automation coverage. Who you are We're looking for someone who meets the minimum requirements to be considered for the role. If you meet these requirements, you are encouraged to apply. The preferred qualifications are a bonus, not a requirement. Minimum requirements - Experience: 7+ years of experience in Financial Crimes, Compliance, or Risk Management, with a focus on program management, enablement, or strategy (fintech or high-growth environments preferred). - Domain Expertise: Deep understanding of AML and Sanctions typologies and the ability to operationalize threat intelligence into measurable detection lift and execution frameworks. - Policy to Standard Translation: Proven track record of taking high-level compliance policies and "designing" them into highly effective, 1LoD operational standards. - Program Effectiveness & Resilience: Experience evaluating program health and demonstrating structural soundness during external reviews, banking partner due diligence, or regulatory exams. - Program-Level Remediation: Demonstrated ability to drive durable, program-level improvements that prevent recurrence, reduce operational friction, and ensure the timely closure of systemic gaps. - Problem Solving: Ability to navigate non-binary risk decisions, such as optimizing risk-adjusted expansion for high-risk business segments while maintaining rigorous program integrity. Additionally, the ability to navigate varying global regulations to build unified, scalable core programs. - Governance Mindset: Experience managing incident remediation and the closure of audit board issues through systemic process enhancements rather than temporary fixes. - Cross-Functional Influence: Demonstrated ability to partner with Engineering, Data Science, Controls, and Product to implement AI-native capabilities and technology-driven solutions into risk systems. Preferred qualifications - Global Compliance Exposure - Experience working with organizations operating on a global scale and required to adhere to multiple jurisdictional requirements. - Technical Proficiency: Experience with data analysis tools (SQL) to measure program effectiveness, track health metrics, and identify coverage gaps. - AI/Automation Experience: Familiarity with implementing or testing AI-native investigative capabilities (e.g., defining performance benchmarks for LLM prompt tuning or auto-adjudication). - Specialized Typologies: Experience with crypto/digital asset compliance, financial services providers, fundraisers, and other high-risk industries. - Law Enforcement & Public-Private Partnerships: Experience engaging with law enforcement agencies (e.g., FBI, IRS-CI, DEA, HSI) and participating in public-private partnership initiatives to share typologies and enhance financial crime detection capabilities.

United States + 1 moreAll locations: United States | Canada
Job Closed
JobMatchingPartner logo

AML Compliance Officer – Part time

JobMatchingPartner

Recruitment with a passion for Quality over Quantity

Financial Crime101 days ago
Part TimeRemoteTeam 1-10H1B No Sponsor

• Prepare, review, and update AML/KYC reports, including risk assessments, risk appetite statements, regulatory reports, and quarterly RC reports • Attend on-site visits or online KYC review meetings, prepare visit reports, and review reports prepared by associates • Conduct internal audits of existing client files to ensure compliance • Act as RC for CSSF and/or AED-supervised clients or funds • Participate in weekly team meetings to align on priorities and projects • Review, update, and deliver AML training materials and sessions to clients, including live or face-to-face sessions • Maintain the AML framework and templates (due diligence questionnaires, AML policies, risk assessments) in line with regulatory requirements • Keep up to date with relevant regulatory developments and ensure inclusion in client reports • Conduct due diligence on service providers and review related reports • Review Director and Officer Insurance documentation to ensure proper coverage • Review and update internal processes and procedures, communicating approved changes to staff, contractors, or other relevant parties • Support compliance consulting engagements on AML/CFT, ESG, or regulatory matters • Monitor and approve daily name screening alerts • Assist in drafting internal documents and procedures, including business continuity planning (BCP) • Log all work in the time monitoring system and adhere to internal procedures

Malta
€20K / year
Job Closed