Fraud Detection Lead Analyst II

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

Benefits offered by this job

Medical, dental, vision coverage

401(k) retirement savings

Paid time off

Job summary

CVS Health is seeking a Fraud, Waste, and Abuse (FWA) Analyst II to identify and develop potential healthcare fraud leads through data mining, claims analysis, and investigative research. The role supports the SIU lead development process across providers, members, and facilities.

The Analyst II uses claims data, business rules, and industry intelligence to assess potential FWA concerns and determine if they warrant formal investigation, requiring strong analytical skills and healthcare claims

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

Analytical thinking

Healthcare data analysis

Claims analysis

Data interpretation

Travel readiness

Education

Bachelor's degree or equivalent

Tools

Tableau

SQL

Power BI

JIRA

SAS

Job description

CVS Health is seeking a Fraud, Waste, and Abuse (FWA) Analyst II to identify and develop potential healthcare fraud leads through data mining, claims analysis, and investigative research. The role supports the SIU lead development process across providers, members, and facilities.

The Analyst II uses claims data, business rules, and industry intelligence to assess potential FWA concerns and determine if they warrant formal investigation, requiring strong analytical skills and healthcare claims