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 Summary
The 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 - $93,574.80
This 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 Health
We anticipate the application window for this opening will close on: 02/18/2025
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
Top Skills
What We Do
CVS Health is the leading health solutions company that delivers care in ways no one else can. We reach people in more ways and improve the health of communities across America through our local presence, digital channels and our nearly 300,000 dedicated colleagues – including more than 40,000 physicians, pharmacists, nurses and nurse practitioners.
Wherever and whenever people need us, we help them with their health – whether that’s managing chronic diseases, staying compliant with their medications, or accessing affordable health and wellness services in the most convenient ways. We help people navigate the health care system – and their personal health care – by improving access, lowering costs and being a trusted partner for every meaningful moment of health. And we do it all with heart, each and every day.
