SIU Fraud Lead & Data Insight Analyst II

CVS Health Corporation; Topeka (KS); 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

Wellness programs

Job summary

CVS Health Corporation seeks an FWA Analyst II to identify and develop potential healthcare fraud leads through data mining, claims analysis, and investigative research. You will evaluate provider, member, pharmacy, and ancillary billing patterns for signs of fraud, waste, abuse, and other anomalies.

You will analyze CPT, HCPCS, ICD, DRG, and NDC data, prepare lead summaries, and present findings to 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

Analytical thinking

Critical thinking

Communication skills

Presentation skills

Team collaboration

Education

Bachelor's degree

Tools

Tableau

SQL

JIRA

Power BI

SAS

Job description

CVS Health Corporation seeks an FWA Analyst II to identify and develop potential healthcare fraud leads through data mining, claims analysis, and investigative research. You will evaluate provider, member, pharmacy, and ancillary billing patterns for signs of fraud, waste, abuse, and other anomalies.

You will analyze CPT, HCPCS, ICD, DRG, and NDC data, prepare lead summaries, and present findings to SIU leadership.