SIU Lead Review Analyst II – Fraud Detection

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

Benefits offered by this job

Medical, Dental, Vision

Paid Time Off

Retirement Savings Options

Wellness Programs

Job summary

CVS Health Corporation in Springfield, IL 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 provider, member, pharmacy, and ancillary billing patterns for signs of fraud, waste, and abuse, while preparing lead summaries and presenting findings to SIU leadership.

This role requires collaboration with investigators, legal, compliance, and business

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.
• Analyze CPT, HCPCS, ICD, DRG, NDC, modifier usage, and reimbursement trends.
• Prepare lead summaries outlining allegations, evidence, and risk indicators.
• Present analytical findings to SIU leadership and investigators.
• Collaborate with investigators, legal, compliance, and business partners on FWA concerns.
• Ensure activities comply with CMS, state regulations, and SIU procedures.

Skills

Healthcare data analysis

SIU experience

Claims analysis

Auditing

Payment integrity

Fraud experience

Tableau

SQL

JIRA

Power BI

SAS

Education

Bachelor's degree or equivalent

Tools

Tableau

SQL

JIRA

Power BI

SAS

Job description

CVS Health Corporation in Springfield, IL 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 provider, member, pharmacy, and ancillary billing patterns for signs of fraud, waste, and abuse, while preparing lead summaries and presenting findings to SIU leadership.

This role requires collaboration with investigators, legal, compliance, and business