Job Description

Special Investigations Unit Lead Reviewer

At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day. This position can be work from home anywhere in the United States. The Special Investigations Unit (SIU) is looking for an analytically driven individual who is skilled at identifying outliers through data extraction and analysis, dedicated to a specific self-funded plan sponsor. The lead reviewer is accountable for the validation of existing fraud waste and abuse business rules and leads designed to detect aberrant billing patterns and reviewing incoming referrals and leads to determine if additional investigations are warranted.

Key Responsibilities:

• Identify, research, analyze and document analytic leads or referrals to send for investigative review.
• Review company clinical and payment policies to determine the impact of the scheme on Aetna business.
• Keep current with new and emerging fraud, waste, and abuse schemes and trends through training sessions and industry resources.
• Communicate with colleagues, verbally and in writing, findings related to data analysis and internal/external leads.
• Process customer leads and referrals quickly and accurately, adhering to plan sponsor mandated turnaround times.
• Conduct proactive data mining and analysis if needed to identify suspicious billing patterns.

Required Qualifications:

• 3-5 years of data interpretation and analysis experience.
• Healthcare background.
• Experience with internal claims data and healthcare coding.
• Must be able to travel to provide testimony if needed.
• Experience with Excel.

Preferred Qualifications:

• Certified Professional Coder.
• Knowledge of CVS/Aetna's policies and procedures.
• Excellent verbal and written communication skills.

Education:

Bachelor's degree preferred or equivalent work experience.

Anticipated Weekly Hours: 40

Time Type: Full time

Pay Range: The typical pay range for this role is: $43,888.00 - $102,081.00

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

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