FWA Lead Analyst II: Data & Fraud Insights

NHSHP; New Hampshire; Hybrid; USD 44,000 - 94,000; Full time

Job summary

CVS Health is seeking a Fraud, Waste, and Abuse (FWA) Analyst II to identify and develop healthcare fraud leads through data mining, claims analysis, and investigative research. The role contributes to SIU lead development, evaluates billing patterns for signs of fraud or abuse, and translates complex data into actionable leads and recommendations.

The position requires strong analytical skills, healthcare claims expertise, and the ability to present findings to leadership.

Qualifications

• 3+ years of healthcare data analysis or fraud experience.
• Strong analytical and critical-thinking skills.
• Experience interpreting large datasets and deriving insights.
• Knowledge of 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 credibility and value.
• Examine spike analyses, utilization trends, payment anomalies, and outlier reports for unusual patterns.
• Evaluate provider, member, pharmacy, DME, transportation, and facility billing for indicators of fraud or abuse.
• Monitor 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 records, licensing boards, and sanctions lists.
• Analyze relationships among providers, members, facilities, and associated entities to identify schemes.

Skills

Healthcare data analysis

SIU experience

Claims analysis

Auditing

Healthcare fraud experience

Travel up to 10%

Education

Bachelor's degree or equivalent

Tools

Tableau

SQL

JIRA

Power BI

SAS

Job description

CVS Health is seeking a Fraud, Waste, and Abuse (FWA) Analyst II to identify and develop healthcare fraud leads through data mining, claims analysis, and investigative research. The role contributes to SIU lead development, evaluates billing patterns for signs of fraud or abuse, and translates complex data into actionable leads and recommendations.

The position requires strong analytical skills, healthcare claims expertise, and the ability to present findings to leadership.