SIU Lead Review Analyst: Fraud & Data Analytics

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

Benefits offered by this job

Medical, dental, vision

Paid time off

Retirement benefits

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. You will evaluate billing patterns across providers, members, pharmacies, and facilities for fraud indicators while collaborating with SIU teams.

Key duties include leading investigations, analyzing CPT/HCPCS/ICD data, and delivering actionable recommendations.

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 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.
• 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 entities to identify schemes.

Skills

Healthcare data analysis

Fraud detection

Tableau

SQL

Power BI

SAS

JIRA

CFE

Communication

Education

Bachelor's degree

Tools

Tableau

SQL

Power BI

SAS

JIRA

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. You will evaluate billing patterns across providers, members, pharmacies, and facilities for fraud indicators while collaborating with SIU teams.

Key duties include leading investigations, analyzing CPT/HCPCS/ICD data, and delivering actionable recommendations.