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Lead Review Analyst II – Special Investigation Unit
CVS HealthCore Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in healthcare data analysis, particularly in fraud detection and claims processing, with a strong understanding of coding methodologies and regulatory compliance. Capable of transforming complex datasets into actionable insights while maintaining confidentiality and adhering to organizational policies.
Highest-signal resume keywords
Healthcare Data AnalysisFraud Detection ToolsCPT, HCPCS, ICD-10 CodingCertified Fraud Examiner (CFE)Tableau or Power BI
Tech Stack
Tools & technologiesAbout the role
Key responsibilities & impact- Develop proactive and reactive leads to identify potential fraud, waste, and abuse
- Generate FWA leads by mining claims databases, reporting tools, and investigative systems
- Validate and refine business-rule-generated leads
- Examine spike analyses, utilization trends, payment anomalies, and outlier reports
- Evaluate provider, member, pharmacy, DME, transportation, and facility billing
- Monitor intelligence sources for emerging fraud schemes and patterns
- Perform quantitative and qualitative analysis of medical and pharmacy claims data
- Analyze CPT, HCPCS, ICD, DRG, NDC, modifier usage, and reimbursement trends
- Review provider billing history, peer comparisons, utilization metrics, and financial impact analyses
- Research internal systems, public records, licensing boards, sanctions lists, and other investigative resources
- Analyze relationships among providers, members, facilities, and associated entities
- Develop lead summaries outlining allegations, evidence, and risk indicators
- Present findings and recommendations to SIU leadership and investigative staff
- Determine escalation to formal investigation, monitoring, or closure
- Document investigative rationale and evidence according to SIU policies and regulatory requirements
- Partner with investigators, clinicians, legal, compliance, and business partners
- Participate in fraud trend discussions and special projects
- Support improvements to business rules, data mining, and lead generation methodologies
- Assist with training regarding emerging fraud schemes and healthcare billing practices
- Ensure compliance with CMS, state Medicaid regulations, Medicare requirements, organizational policies, and SIU procedures
- Maintain confidentiality and safeguard sensitive information
- Meet productivity, quality, and timeliness standards
- Support internal audits, quality reviews, and regulatory reporting activities
Requirements
What you’ll need- 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%
- 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
- Working knowledge of CPT, HCPCS, ICD-10, DRG, and NDC coding structures
- Familiarity with healthcare payment methodologies and reimbursement models
- Experience using fraud detection tools, business rule engines, and investigative case management systems
- Experience with Tableau, Power BI, or equivalent analytical platforms
- Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified Professional Coder (CPC), or similar certification
- Excellent verbal, written, and presentation skills
- Strong organizational and time-management abilities with the capability to manage multiple priorities
- Bilingual in English/Spanish
- Bachelor's degree or equivalent combination of education and experience
Benefits
Comp & perks- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources supporting physical, emotional, and financial well-being
- CVS Health bonus, commission or short-term incentive program in addition to base pay
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims AnalysisPayment IntegrityQuantitative AnalysisQualitative AnalysisData MiningUtilization Trends AnalysisBilling EvaluationInvestigative ResearchTrend IdentificationRisk Indicator Development
Soft Skills
Analytical SkillsCritical ThinkingOrganizational AbilitiesTime ManagementPresentation Skills
Tools & Technologies
Business Rule EnginesInvestigative Case Management SystemsReporting ToolsClaims DatabasesData Visualization Platforms
Certifications & Qualifications
Certified Fraud Examiner (CFE)Accredited Healthcare Fraud Investigator (AHFI)Certified Professional Coder (CPC)
Industry Keywords
Fraud, Waste, and Abuse (FWA)Special Investigations Unit (SIU)MedicareMedicaidCommercial Healthcare ProgramsMarketplace Healthcare ProgramsHealthcare Billing PracticesRegulatory ComplianceHealthcare Payment MethodologiesConfidentiality