Lead Review Analyst, Special Investigation Unit

CVS Health

. Develop proactive and reactive leads to identify potential fraud, waste, and abuse .

Posted 9/23/2026full-timeRemote • Oklahoma • United StatesSenior💰 $43,888 - $93,574 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in healthcare data analysis, particularly in identifying fraud, waste, and abuse through quantitative and qualitative methods. Proficient in utilizing coding methodologies and analytical tools to generate actionable insights and ensure compliance with regulatory standards.

Highest-signal resume keywords

Healthcare Data AnalysisFraud Detection ToolsCPT, HCPCS, ICD-10 CodingCertified Fraud Examiner (CFE)Tableau, SQL, Power BI

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims AnalysisPayment IntegrityQuantitative AnalysisQualitative AnalysisData Mining StrategiesInvestigative Case ManagementBilling AnalysisTrend AnalysisAnomaly DetectionLead Generation Methodologies

Soft Skills

Analytical SkillsCritical ThinkingOrganizational AbilitiesTime ManagementPresentation Skills

Tools & Technologies

TableauSQLJIRAPower BISASBusiness Rule Engines

Certifications & Qualifications

Certified Fraud Examiner (CFE)Accredited Healthcare Fraud Investigator (AHFI)Certified Professional Coder (CPC)

Industry Keywords

Healthcare FraudMedicareMedicaidCommercial Healthcare ProgramsMarketplace Healthcare ProgramsSpecial Investigations Unit (SIU)Healthcare Claims ProcessingReimbursement ModelsUtilization TrendsBilling Practices

Tech Stack

Tools & technologies

SQLTableau

About 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 for credibility and investigative value
Examine spike analyses, utilization trends, payment anomalies, and outlier reports
Evaluate provider, member, pharmacy, DME, transportation, and facility billing for fraud or abuse indicators
Monitor internal and external 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 for potential schemes or collusion
Develop lead summaries outlining allegations, evidence, and risk indicators
Present findings and recommendations to SIU leadership and investigative staff
Determine whether findings warrant 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 strategies, and lead generation methodologies
Assist with training and knowledge related to 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) preferred
Knowledge of Medicare, Medicaid, Commercial, and Marketplace healthcare programs preferred
Understanding of medical and pharmacy claim data preferred
Working knowledge of CPT, HCPCS, ICD-10, DRG, and NDC coding structures preferred
Familiarity with healthcare payment methodologies and reimbursement models preferred
Experience using fraud detection tools, business rule engines, and investigative case management systems preferred
Experience with Tableau, SQL, JIRA, Power BI, SAS, or equivalent analytical platforms preferred
Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified Professional Coder (CPC), or similar certification preferred
Excellent verbal, written, and presentation skills preferred
Strong organizational and time-management abilities with the capability to manage multiple priorities preferred
Bachelor's degree or equivalent combination of education and experience

Benefits

Comp & perks

CVS Health bonus, commission or short-term incentive program in addition to base pay
Medical coverage
Dental coverage
Vision coverage
Paid time off
Retirement savings options
Wellness programs
Other resources supporting physical, emotional, and financial well-being
Comprehensive benefits package for eligible full-time colleagues and their families