Special Investigation Unit Lead Review Analyst (Aetna SIU)

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand - with heart at its center - our purpose sends a personal message that how we deliver our services is just as important as what we deliver.

Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.Position SummaryThe Special Investigations Unit (SIU) is looking for an analytically driven individual who is skilled at identifying outliers through data extraction and analysis.The lead reviewer is accountable for the validation of existing Fraud, Waste and Abuse business rules/leads designed to detect aberrant billing patterns as reviewing incoming referrals.

• Research and ad hoc report development to identify fraud, waste and abuse schemes and trends
• Review company clinical & payment policies to determine the impact of the scheme on Aetna business
• Identify all possible issues related to fraud, waste and abuse when reviewing a new lead or referral
• Keep current with new & emerging fraud, waste and abuse schemes and trends through training sessions and industry resources
• Interpret, analyze and present key findings to internal customers (project team, investigators) providing recommendations based on analytical findings

Required Qualifications

• 3-5 years of data interpretation and analysis experience.
• Healthcare background.
• Excellent verbal and written communication skills.
• Experience with healthcare coding
• Must be able to travel to provide testimony if needed
• Advanced experience with Excel

Preferred Qualifications

• A solid understanding of medical and pharmaceutical claim data, medical claims coding (CPT/ICD/NDC), Aetna clinical and payment policies, as well as core Aetna systems (QNXT, ACAS, EWM, EPDB, IOP).
• Some experience using Tableau is a plus.
• Previous healthcare fraud experience
• Experience with Aetna clinical and payment policies
• Certified Professional Coder (CPC) certification is a plus
• Medicaid Experience

Education

• Bachelor's degree or equivalent work experience

Pay Range

The typical pay range for this role is:$43,888.00 - $93,574.80This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities. The Company offers a full range of medical, dental, and vision benefits. Eligible employees may enroll in the Company's 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees. The Company provides a fully-paid term life insurance plan to eligible employees, and short-term and long term disability benefits. CVS Health also offers numerous well-being programs, education assistance, free development courses, a CVS store discount, and discount programs with participating partners. As for time off, Company employees enjoy Paid Time Off ("PTO") or vacation pay, as well as paid holidays throughout the calendar year. Number of paid holidays, sick time and other time off are provided consistent with relevant state law and Company policies.

For more detailed information on available benefits, please visit Benefits | CVS HealthWe anticipate the application window for this opening will close on: 02/18/2025Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.