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Special Investigation Unit Lead Review Analyst

https://www.cvshealth.com/ Logo

CVS Health

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Location:
United States , Remote

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Category:
Customer Service

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Contract Type:
Employment contract

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Salary:

43888.00 - 102081.00 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, dedicated to a specific self-funded plan sponsor. The lead reviewer is accountable for the validation of existing fraud waste and abuse business rules and leads designed to detect aberrant billing patterns and reviewing incoming referrals and leads to determine if additional investigations are warranted.

Job Responsibility:

  • Identify, research, analyze and document analytic leads or referrals to send for investigative review
  • Review company clinical and payment policies to determine the impact of the scheme on Aetna business
  • Keep current with new and emerging fraud, waste, and abuse schemes and trends through training sessions and industry resources
  • Communicate with colleagues, verbally and in writing, findings related to data analysis and internal/external leads
  • Process customer leads and referrals quickly and accurately, adhering to plan sponsor mandated turnaround times
  • Conduct proactive data mining and analysis if needed to identify suspicious billing patterns

Requirements:

  • 3-5 years of data interpretation and analysis experience
  • Healthcare background
  • Experience with internal claims data and healthcare coding
  • Must be able to travel to provide testimony if needed
  • Experience with Excel
  • Bachelor's degree preferred or equivalent work experience

Nice to have:

  • Certified Professional Coder
  • Knowledge of CVS/Aetna's policies and procedures
  • Excellent verbal and written communication skills
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
  • 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 17, 2025

Expiration:
January 03, 2026

Employment Type:
Fulltime
Work Type:
Remote work
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