Lead, Ideation Affordability Decision Scientist

CVS Health•Hartford, CT

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary The Lead, Senior Decision Scientist serves as a strategic analytics and ideation leader supporting Payment Integrity Affordability initiatives with a primary focus on Fraud, Waste & Error (FWE) and Special Investigations Unit (SIU) programs. This role provides leadership and guidance to a team of Decision Scientists while driving the development, evaluation, and implementation of innovative opportunities that improve affordability outcomes and strengthen Payment Integrity capabilities. The Lead Decision Scientist is responsible for establishing analytical frameworks, managing ideation pipelines, defining success metrics, and identifying cross-functional opportunities that create enterprise value across Payment Integrity programs.

Requirements

7+ years of experience in healthcare analytics, Payment Integrity, Fraud, Waste & Error (FWE), Special Investigations, or related healthcare operations.
5+ years of experience leading analytical projects or providing technical leadership within a healthcare environment.
Demonstrated experience working with healthcare claims platforms including ACAS, QNXT, HRP, or comparable systems.
Experience using SAS, SQL, Python, R, or other analytical and statistical programming languages.
Experience performing advanced data analysis, opportunity identification, trend analysis, and business case development.
Strong understanding of healthcare reimbursement methodologies, coding principles, and Payment Integrity programs.
Proven ability to communicate complex analytical findings to both technical and non-technical audiences.
Bachelor's degree in Business Analytics, Data Science, Healthcare Administration, Statistics, Economics, Computer Science, or a related field; equivalent combination of education and experience considered.

Nice To Haves

Accredited Healthcare Fraud Investigator (AHFI®) Certification
Certified Professional Coder (CPC) certification
Strong analytical problem-solving and critical-thinking skills.
Demonstrated ability to perform independent research and translate findings into actionable recommendations.
Excellent written, verbal, and presentation communication skills.
Strong attention to detail and organizational skills.
Ability to influence stakeholders and build collaborative partnerships across multiple functions.
Experience utilizing enterprise data sources, investigative tools, and healthcare analytics platforms.
Working knowledge of Aetna/CVS Health policies, procedures, and Payment Integrity operations preferred.

Responsibilities

Provide day-to-day leadership, coaching, and mentorship to Decision Scientists while fostering a culture of innovation, collaboration, and accountability.
Assist leadership with recruitment, interviewing, onboarding, training, and development of team members.
Monitor workload prioritization and ensure timely progression of ideation concepts from intake through implementation.
Establish and monitor performance expectations, project milestones, and quality standards for analytical deliverables.
Partner with internal business teams including Special Investigations Unit (SIU), Analytics & Behavior Change (A&BC), Clinical Policy, Medical Economics, and Payment Integrity leaders to identify affordability and program improvement opportunities.
Lead the intake, evaluation, prioritization, and governance of affordability and ideation opportunities.
Identify emerging risks, trends, and operational challenges and recommend data-driven solutions.
Develop long-term measurement frameworks and success metrics to evaluate ideation outcomes and business value realization.
Identify synergies and scalability opportunities across Payment Integrity programs and initiatives.
Consult business partners to understand strategic goals, operational challenges, and analytical requirements.
Analyze complex healthcare, claims, provider, and investigative data to identify patterns, trends, anomalies, and opportunities.
Research, manipulate, and prepare large-scale datasets using statistical and analytical techniques.
Develop integrated analytic datasets, dashboards, reports, studies, and predictive analyses to support business decision-making.
Collaborate with Data Scientists, Medical Directors, Medical Economics, Payment Integrity, and Investigative teams to refine analytical methodologies and solution effectiveness.
Evaluate the effectiveness of implemented opportunities and recommend iterative improvements.
Present analyses and recommendations to leaders and stakeholders across multiple organizational levels.
Lead ideation sessions and facilitate opportunity-generation activities across stakeholder groups.
Develop business cases and value assessments supporting affordability opportunities.
Maintain ideation governance processes including intake, prioritization, tracking, and outcome measurement.
Develop executive-ready presentations and recommendations for senior leadership.
Communicate analytical findings, risks, opportunities, and implementation considerations to decision-makers.
Evaluate emerging analytical methodologies, automation opportunities, and AI-enabled solutions that support Payment Integrity objectives.
Identify opportunities to enhance analytical efficiency through advanced tools, automation, and predictive modeling.