SIU Lead Analyst - Fraud, Data & Investigations

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

Job summary

CVS Health Corporation is seeking an experienced 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.

The role requires 3+ years of healthcare data analysis or related experience, a Bachelor’s degree, strong analytical skills, and the ability to travel up to 10%.

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.
• Analyze CPT, HCPCS, ICD, DRG, NDC coding usage and reimbursement trends.
• Review provider billing history, peer comparisons, utilization metrics, and financial impact analyses.
• Conduct research utilizing internal systems, external public records, licensing boards, sanctions lists, and other investigative resources.
• Analyze relationships among providers, members, facilities, and associated entities to identify potential schemes or collusive activity.
• Develop comprehensive lead summaries outlining allegations, supporting evidence, and identified risk indicators.
• Present analytical findings and recommendations to SIU leadership and investigative staff.
• Determine whether findings support escalation to a formal investigation, monitoring activity, or closure.
• Document evidentiary rationale and supporting documentation per SIU policies and regulatory requirements.
• Provide actionable recommendations based on analytical findings and business intelligence.
• Partner with investigators, clinicians, legal, compliance, and business partners regarding potential FWA concerns.
• Participate in fraud trend discussions and special projects to strengthen detection efforts.

Skills

Data mining

Claims analysis

Analytical thinking

Communication

Education

Bachelor's degree or equivalent

Tools

Tableau

SQL

Power BI

JIRA

SAS

Job description

CVS Health Corporation is seeking an experienced 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.

The role requires 3+ years of healthcare data analysis or related experience, a Bachelor’s degree, strong analytical skills, and the ability to travel up to 10%.