SIU Lead: Fraud Analytics & Review Analyst II

Careerwebsite; Concord, Northern (NH, KY); 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 potential healthcare fraud leads through data mining, claims analysis, and investigative research. You will evaluate billing patterns across providers, members, pharmacies, and related entities to detect fraud or abuse and translate findings into actionable leads for escalation or resolution.

In this role, you will perform quantitative and qualitative analyses of medical and pharmacy claims, collaborate with

Qualifications

• Bachelor's degree or equivalent combination of education and experience.
• Experience in healthcare claims processing, auditing, or fraud detection.
• Strong analytical and critical-thinking skills with the ability to identify trends and anomalies.
• 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, and payment anomalies for unusual 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.
• 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.
• Document investigative rationale and supporting evidence in accordance with policies.
• Present findings and recommendations to SIU leadership and investigators.
• Determine escalation to formal investigation, monitoring, or closure.

Skills

Healthcare data analysis

SIU experience

Claims analysis

Analytical thinking

Data interpretation

Communication

Attention to detail

Regulatory knowledge

Education

Bachelor's degree or equivalent

Tools

Tableau

SQL

Power BI

SAS

JIRA

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. You will evaluate billing patterns across providers, members, pharmacies, and related entities to detect fraud or abuse and translate findings into actionable leads for escalation or resolution.

In this role, you will perform quantitative and qualitative analyses of medical and pharmacy claims, collaborate with