Fraud & Data Insights Lead Analyst (SIU)

CVS Health Corporation; Atlanta (GA); On-site; USD 44,000 - 94,000; Full time

Benefits offered by this job

Medical, dental, and vision coverage

Paid time off

Retirement savings options

Job summary

CVS Health Corporation is hiring an Analyst II for the Fraud, Waste, and Abuse (FWA) program. You will identify potential fraud leads through data mining, claims analysis, and investigative research, evaluating provider, member, pharmacy, and ancillary billing patterns for fraud, waste, abuse, and anomalies.

You will perform quantitative and qualitative analyses of medical and pharmacy claims data, review coding structures, and develop lead summaries for SIU leadership.

Qualifications

• 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%.

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.

Skills

Healthcare data analysis

Claims analysis

Analytical thinking

Communication skills

Travel up to 10%

Education

Bachelor's degree

Tools

Tableau

SQL

JIRA

Power BI

SAS

Job description

CVS Health Corporation is hiring an Analyst II for the Fraud, Waste, and Abuse (FWA) program. You will identify potential fraud leads through data mining, claims analysis, and investigative research, evaluating provider, member, pharmacy, and ancillary billing patterns for fraud, waste, abuse, and anomalies.

You will perform quantitative and qualitative analyses of medical and pharmacy claims data, review coding structures, and develop lead summaries for SIU leadership.