SIU Lead: Health Fraud & Data Investigation

CVS Health Corporation; Frankfort (KY); Presencial; USD 44.000 - 94.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Health insurance

Retirement plan

Paid time off

Wellness programs

Bonus eligibility

Descripción de la vacante

CVS Health Corporation seeks a Fraud, Waste, and Abuse Analyst II to identify and develop healthcare fraud leads through data mining, claims analysis, and investigative research within the SIU.

You will analyze CPT, HCPCS, ICD, DRG, and NDC coding, review provider billing history and utilization patterns, and collaborate with investigators to deliver actionable findings and risk assessments.

Formación

• 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%

Responsabilidades

• 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 and unusual billing patterns for indicators of fraud.
• Evaluate provider, member, pharmacy, DME, and facility billing for indicators of fraud or abuse.
• Monitor internal and external 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 public records, licensing boards, sanctions lists, and other 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 investigative rationale and supporting evidence in accordance with 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 aimed at strengthening fraud detection efforts.
• Support continuous improvement initiatives involving business rules, data mining strategies, and lead generation methodologies.
• Assist with training and knowledge related to emerging fraud schemes and healthcare billing practices.
• Ensure all activities comply with CMS, state Medicaid regulations, Medicare requirements, organizational policies, and SIU procedures.
• Maintain confidentiality and safeguard sensitive information.
• Meet departmental productivity, quality, and timeliness standards.
• Support internal audits, quality reviews, and regulatory reporting activities.

Conocimientos

Healthcare data analysis

Claims analysis

Data mining

Tableau

SQL

Power BI

JIRA

Educación

Bachelor's degree

Herramientas

Tableau

SQL

JIRA

Power BI

SAS

Descripción del empleo

CVS Health Corporation seeks a Fraud, Waste, and Abuse Analyst II to identify and develop healthcare fraud leads through data mining, claims analysis, and investigative research within the SIU.

You will analyze CPT, HCPCS, ICD, DRG, and NDC coding, review provider billing history and utilization patterns, and collaborate with investigators to deliver actionable findings and risk assessments.