SIU Senior Analyst, Lead Investigator (Must Reside in Maryland)

CVS Health

3d

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. 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

• 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

• This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families.
• The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.
• Additional details about available benefits are provided during the application process and on Benefits Moments.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level