Special Investigation Unit Lead Review Analyst, CVS Health

CVS Health

Location:
United States, Work at Home

Category:
Customer Service

Contract Type:
Employment contract

Salary:

43888.00 - 76500.00 USD / Year

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Job Description:

The Special Investigations Unit (SIU) is looking for an analytically driven individual who is skilled at identifying outliers through data extraction and analysis. The lead reviewer is accountable for the validation of existing Fraud, Waste and Abuse business rules/leads designed to detect aberrant billing patterns as reviewing incoming referrals.

Job Responsibility:

Validation of existing Fraud, Waste and Abuse business rules/leads designed to detect aberrant billing patterns
Reviewing incoming referrals
Research and ad hoc report development to identify fraud, waste and abuse schemes and trends
Review company clinical & payment policies to determine the impact of the scheme on Aetna business
Identify all possible issues related to fraud, waste and abuse when reviewing a new lead or referral
Keep current with new & emerging fraud, waste and abuse schemes and trends through training sessions and industry resources
Interpret, analyze and present key findings to internal customers (project team, investigators) providing recommendations based on analytical findings

Requirements:

3-5 years of data interpretation and analysis experience
Healthcare background
Excellent verbal and written communication skills
Experience with healthcare coding
Must be able to travel to provide testimony if needed
Advanced experience with Excel
Bachelor's degree or equivalent work experience

Nice to have:

Solid understanding of medical and pharmaceutical claim data, medical claims coding (CPT/ICD/NDC), Aetna clinical and payment policies, as well as core Aetna systems (QNXT, ACAS, EWM, EPDB, IOP)
Some experience using Tableau
Previous healthcare fraud experience
Experience with Aetna clinical and payment policies
Certified Professional Coder (CPC) certification
Medicaid Experience

What we offer:

Affordable medical plan options
401(k) plan with matching company contributions
Employee stock purchase plan
Wellness screenings
Tobacco cessation and weight management programs
Confidential counseling and financial coaching
Paid time off
Flexible work schedules
Family leave
Dependent care resources
Colleague assistance programs
Tuition assistance
Retiree medical access

Additional Information:

Job Posted:
November 07, 2025

Expiration:
November 11, 2025

Employment Type:

Fulltime

Work Type:

Remote work

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Special Investigation Unit Lead Review Analyst