Lead Review Analyst II – Special Investigation Unit

This is a fully remote position, open to applicants in Florida.

📋 Description

• Develop both proactive and reactive leads to uncover potential fraud, waste, and abuse.

• Generate leads for FWA by analyzing claims databases, reporting tools, and investigative systems.

• Validate and enhance leads generated by business rules.

• Investigate spike analyses, utilization trends, payment anomalies, and outlier reports.

• Assess billing for providers, members, pharmacies, DME, transportation, and facilities.

• Monitor intelligence sources to identify emerging fraud schemes and patterns.

• Conduct quantitative and qualitative analyses of medical and pharmacy claims data.

• Analyze trends in CPT, HCPCS, ICD, DRG, NDC, and modifier usage, as well as reimbursement patterns.

• Review provider billing history, peer comparisons, utilization metrics, and financial impact analyses.

• Conduct research using internal systems, public records, licensing boards, sanctions lists, and other investigative resources.

• Analyze the relationships among providers, members, facilities, and related entities.

• Create lead summaries that outline allegations, evidence, and risk indicators.

• Present findings and recommendations to SIU leadership and investigative teams.

• Decide on the escalation of cases to formal investigations, monitoring, or closure.

• Document investigative rationale and evidence in accordance with SIU policies and regulatory requirements.

• Collaborate with investigators, clinicians, legal, compliance, and business partners.

• Engage in discussions about fraud trends and participate in special projects.

• Contribute to enhancements of business rules, data mining, and lead generation strategies.

• Assist with training on emerging fraud schemes and healthcare billing practices.

• Ensure adherence to CMS, state Medicaid regulations, Medicare requirements, organizational policies, and SIU procedures.

• Maintain confidentiality and protect sensitive information.

• Meet productivity, quality, and timeliness benchmarks.

• Support internal audits, quality reviews, and regulatory reporting activities.

⛳️ Requirements

• Over 3 years of experience in healthcare data analysis, SIU, claims analysis, auditing, payment integrity, or healthcare fraud.

• Strong analytical and critical thinking skills to identify trends and anomalies.

• Proficient in interpreting large healthcare datasets and converting findings into actionable insights.

• Familiarity with healthcare claims processing and coding methodologies.

• Willingness to travel up to 10%.

• Experience in a healthcare payer Special Investigations Unit (SIU).

• Knowledge of Medicare, Medicaid, Commercial, and Marketplace healthcare programs.

• Understanding of medical and pharmacy claim data.

• Proficient in CPT, HCPCS, ICD-10, DRG, and NDC coding structures.

• Familiarity with healthcare payment methodologies and reimbursement models.

• Experience utilizing fraud detection tools, business rule engines, and investigative case management systems.

• Proficient with analytical platforms such as Tableau, Power BI, or equivalents.

• Certification as a Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified Professional Coder (CPC), or similar credential.

• Exceptional verbal, written, and presentation skills.

• Strong organizational and time-management skills with the ability to juggle multiple priorities.

• Bilingual in English and Spanish.

• Bachelor's degree or a comparable combination of education and experience.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources supporting physical, emotional, and financial well-being.

• CVS Health bonus, commission, or short-term incentive program in addition to base salary.