SIU Fraud & Data Insights Lead

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

Benefits offered by this job

Medical, Dental, Vision coverage

Paid time off

Retirement savings options

Wellness programs

Job summary

CVS Health Corporation 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 evaluates provider, member, pharmacy, and ancillary billing patterns for signs of fraud, waste, and abuse while collaborating with SIU leadership and investigators.

You will perform detailed quantitative and qualitative analysis of medical and pharmacy claims data, review billing history

Qualifications

• Bachelor's degree or equivalent combination of education and experience.
• 3+ years of healthcare data analysis, SIU, claims analysis, auditing, payment integrity, or healthcare fraud experience.
• Strong analytical and critical-thinking skills with ability to identify trends and anomalies.
• Experience interpreting large healthcare datasets and transforming findings into actionable insights.

Responsibilities

• Identify potential fraud leads through data mining of claims data and investigative research.
• Analyze CPT, HCPCS, ICD, DRG, NDC, and reimbursement trends to detect anomalies.
• Develop lead summaries with supporting evidence and risk indicators.
• Present findings and recommendations to SIU leadership and investigators.
• Collaborate with investigators, legal, and compliance to address FWA concerns.
• Support continuous improvement of data mining strategies and rules.

Skills

Tableau

SQL

Power BI

JIRA

SAS

CFE

AHFI

CPC

Excellent communication

Education

Bachelor's degree or equivalent

Tools

Tableau

SQL

Power BI

JIRA

SAS

Job description

CVS Health Corporation 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 evaluates provider, member, pharmacy, and ancillary billing patterns for signs of fraud, waste, and abuse while collaborating with SIU leadership and investigators.

You will perform detailed quantitative and qualitative analysis of medical and pharmacy claims data, review billing history