Lead Review Analyst, Special Investigation Unit

Job not on LinkedIn

🔥 14 hours ago

🌪️ Oklahoma – Remote

🌪️ Oklahoma – Remote

💵 $43.9k - $93.6k / year

⏰ Full Time

🟠 Senior

🧐 Analyst

👻 Ghost score 0%

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CVS Health

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1963

🏥 Healthcare

⚕️ Healthcare Insurance

🛒 Retail

Healthcare • Healthcare Insurance • Retail

CVS Health is a leading American healthcare company dedicated to improving health access and affordability. The company focuses on a comprehensive approach that includes health services, health insurance, and pharmacy benefits management. Through its subsidiaries, such as Aetna and CVS Caremark, CVS Health offers a range of services that facilitate wellness, condition management, and affordable prescription drug coverage. CVS Health operates neighborhood pharmacies, provides mail-order pharmacy services, and manages specialty medication programs, aiming to make healthcare convenient and accessible for everyone. Driven by a mission to connect people with essential care services, CVS Health is committed to fostering healthier communities and supporting the wellbeing of all individuals.

📋 Description

• 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 business-rule-generated leads for credibility and investigative value • Examine spike analyses, utilization trends, payment anomalies, and outlier reports • Evaluate provider, member, pharmacy, DME, transportation, and facility billing for fraud or abuse indicators • Monitor internal and external intelligence sources for emerging fraud schemes and patterns • Perform 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 • Research internal systems, public records, licensing boards, sanctions lists, and other investigative resources • Analyze relationships among providers, members, facilities, and associated entities for potential schemes or collusion • Develop lead summaries outlining allegations, evidence, and risk indicators • Present findings and recommendations to SIU leadership and investigative staff • Determine whether findings warrant formal investigation, monitoring, or closure • Document investigative rationale and evidence according to SIU policies and regulatory requirements • Partner with investigators, clinicians, legal, compliance, and business partners • Participate in fraud trend discussions and special projects • Support improvements to business rules, data mining strategies, and lead generation methodologies • Assist with training and knowledge related to emerging fraud schemes and healthcare billing practices • Ensure compliance with CMS, state Medicaid regulations, Medicare requirements, organizational policies, and SIU procedures • Maintain confidentiality and safeguard sensitive information • Meet productivity, quality, and timeliness standards • Support internal audits, quality reviews, and regulatory reporting activities

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

🏖️ Benefits

• CVS Health bonus, commission or short-term incentive program in addition to base pay • Medical coverage • Dental coverage • Vision coverage • Paid time off • Retirement savings options • Wellness programs • Other resources supporting physical, emotional, and financial well-being • Comprehensive benefits package for eligible full-time colleagues and their families