Special Investigation Unit Lead Review Analyst II (Aetna SIU)

CVS Health•Work At Home-Georgia, GA

13d•$43,888 - $93,574•Remote

About The Position

The Fraud, Waste, and Abuse (FWA) Analyst II identifies and develops potential healthcare fraud leads through data mining, claims analysis, and investigative research. As a key contributor to the SIU lead development process, this role evaluates provider, member, pharmacy, and ancillary healthcare billing patterns for signs of fraud, waste, abuse, and other anomalies. The Analyst II uses internal claims data, analytical tools, business rule results, and industry intelligence to assess potential FWA concerns and determine whether they warrant formal investigation. This role requires strong analytical skills, healthcare claims expertise, and the ability to translate complex data into actionable investigative leads and recommendations.

Requirements

3+ years of healthcare data analysis, SIU, claims analysis, auditing, payment integrity, or healthcare fraud experience.
Strong analytical and critical-thinking skills with the ability to identify trends and anomalies.
Experience interpreting large healthcare datasets and transforming findings into actionable insights.
Working knowledge of healthcare claims processing and coding methodologies.
Ability to travel up to 10%

Nice To Haves

Experience in a healthcare payer Special Investigations Unit (SIU).
Knowledge of Medicare, Medicaid, Commercial, and Marketplace healthcare programs.
Understanding of medical and pharmacy claim data.
Working knowledge of CPT, HCPCS, ICD-10, DRG, and NDC coding structures.
Familiarity with healthcare payment methodologies and reimbursement models.
Experience using fraud detection tools, business rule engines, and investigative case management systems.
Experience with Tableau, SQL, JIRA, Power BI, SAS, or equivalent analytical platforms.
Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified Professional Coder (CPC), or similar certification.
Excellent verbal, written, and presentation skills.
Strong organizational and time-management abilities with the capability to manage multiple priorities.

Responsibilities

Develop proactive and reactive leads to identify potential fraud, waste, and abuse.
Generate FWA leads by mining claims databases, reporting tools, and investigative systems.
Validate and refine leads generated by business rules to assess their credibility and investigative value.
Examine spike analyses, utilization trends, payment anomalies, and outlier reports for unusual billing patterns.
Evaluate provider, member, pharmacy, DME, transportation, and facility billing for indicators of fraud or abuse.
Monitor internal and external intelligence sources to detect emerging fraud schemes and patterns.
Perform detailed quantitative and qualitative analysis of medical and pharmacy claims data.
Analyze CPT, HCPCS, ICD, DRG, NDC, modifier usage, and reimbursement trends.
Review provider billing history, peer comparisons, utilization metrics, and financial impact analyses.
Conduct research utilizing internal systems, external public records, licensing boards, sanctions lists, and other investigative resources.
Analyze relationships among providers, members, facilities, and associated entities to identify potential schemes or collusive activity.
Develop comprehensive lead summaries outlining allegations, supporting evidence, and identified risk indicators.
Present analytical findings and recommendations to SIU leadership and investigative staff.
Determine whether findings support escalation to a formal investigation, monitoring activity, or closure.
Document investigative rationale and supporting evidence in accordance with SIU policies and regulatory requirements.
Provide actionable recommendations based on analytical findings and business intelligence.
Partner with investigators, clinicians, legal, compliance, and business partners regarding potential FWA concerns.
Participate in fraud trend discussions and special projects aimed at strengthening fraud detection efforts.
Support continuous improvement initiatives involving business rules, data mining strategies, and lead generation methodologies.
Assist with training and knowledge related to emerging fraud schemes and healthcare billing practices.
Ensure all activities comply with CMS, state Medicaid regulations, Medicare requirements, organizational policies, and SIU procedures.
Maintain confidentiality and safeguard sensitive information.
Meet departmental productivity, quality, and timeliness standards.
Support internal audits, quality reviews, and regulatory reporting activities.