Lead Review Analyst, Special Investigation Unit

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

📋 Description

• Proactively and reactively generate leads to detect potential fraud, waste, and abuse.

• Create FWA leads through analysis of claims databases, reporting instruments, and investigative systems.

• Validate and enhance business-rule-generated leads for reliability and investigative significance.

• Scrutinize spike analyses, utilization patterns, payment discrepancies, and outlier reports.

• Assess billing from providers, members, pharmacies, DME, transportation, and facilities for indicators of fraud or abuse.

• Track internal and external intelligence sources for new fraud schemes and patterns.

• Conduct both quantitative and qualitative analysis of medical and pharmacy claims data.

• Examine CPT, HCPCS, ICD, DRG, NDC, modifier usage, and reimbursement trends.

• Analyze provider billing history, peer comparisons, utilization metrics, and financial impact assessments.

• Research internal systems, public records, licensing boards, sanctions lists, and other investigative resources.

• Investigate relationships among providers, members, facilities, and related entities for potential schemes or collusion.

• Prepare lead summaries detailing allegations, evidence, and risk indicators.

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

• Assess whether findings necessitate formal investigation, monitoring, or closure.

• Document investigative reasoning and evidence in accordance with SIU policies and regulatory standards.

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

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

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

• Assist in training related to 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.

• Achieve productivity, quality, and timeliness benchmarks.

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

⛳️ Requirements

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

• Strong analytical and critical-thinking skills with a talent for identifying trends and anomalies.

• Proficient in interpreting large healthcare datasets and translating 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) is preferred.

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

• Understanding of medical and pharmacy claim data is preferred.

• Working knowledge of CPT, HCPCS, ICD-10, DRG, and NDC coding frameworks is preferred.

• Familiarity with healthcare payment methodologies and reimbursement models is preferred.

• Experience using fraud detection tools, business rule engines, and investigative case management systems is preferred.

• Proficient with Tableau, SQL, JIRA, Power BI, SAS, or similar analytical platforms is preferred.

• Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified Professional Coder (CPC), or similar certification is preferred.

• Excellent verbal, written, and presentation skills are preferred.

• Strong organizational and time-management skills with the ability to manage multiple priorities are preferred.

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

🏝️ Benefits

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

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

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

• Comprehensive benefits package for eligible full-time colleagues and their families.