SIU Senior Analyst, Investigator (Must Reside in Maryland)
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 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.
Requirements
- Must reside in Maryland
- 5+ years of claim data interpretation and analysis experience.
- Solid understanding of medical and pharmaceutical claim data, medical claims coding (CPT/HCPCS/ICD/NDC)
- Advanced analytical and research skills, with the ability to independently identify and source information.
- Advanced experience with Excel
- Healthcare Insurance background.
- Excellent verbal and written communication skills.
- Experience with healthcare coding
- Must be able to travel to provide testimony if needed
Nice To Haves
- Aetna clinical and payment policies, as well as core Aetna systems (QNXT, , SCOUT, Discover +, IOP).
- Previous healthcare fraud experience
- Experience with Aetna clinical and payment policies
- Certified Professional Coder (CPC) certification
- Medicaid Experience
Responsibilities
- 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
Benefits
- medical
- dental
- vision coverage
- paid time off
- retirement savings options
- wellness programs
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Senior
