We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time.
Position Summary
The Special Investigations Unit (SIU) is looking for an analytically driven individual who is skilled at identifying outliers through data extraction and analysis.
The lead reviewer is accountable for the validation of existing Fraud, Waste and Abuse business rules/leads designed to detect aberrant billing patterns as reviewing incoming referrals.
- Research and ad hoc report development to identify fraud, waste and abuse schemes and trends
- Review company clinical & payment policies to determine the impact of the scheme on Aetna business
- Identify all possible issues related to fraud, waste and abuse when reviewing a new lead or referral
- Keep current with new & emerging fraud, waste and abuse schemes and trends through training sessions and industry resources
- Interpret, analyze and present key findings to internal customers (project team, investigators) providing recommendations based on analytical findings
Required Qualifications
- Must reside in Maryland
- 5+ years of claim data interpretation and analysis experience.
- Solid understanding of medical and pharmaceutical claim data, medical claims coding (CPT/HCPCS/ICD/NDC)
- Advanced analytical and research skills, with the ability to independently identify and source information.
- Advanced experience with Excel
- Healthcare Insurance background.
- Excellent verbal and written communication skills.
- Experience with healthcare coding
- Must be able to travel to provide testimony if needed
Preferred Qualifications
- Aetna clinical and payment policies, as well as core Aetna systems (QNXT, , SCOUT, Discover +, IOP).
- Previous healthcare fraud experience
- Experience with Aetna clinical and payment policies
- Certified Professional Coder (CPC) certification
- Medicaid Experience
Education
- Bachelor's degree or equivalent work experience
Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$46,988.00 - $112,200.00This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.
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
We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
Additional details about available benefits are provided during the application process and on Benefits Moments.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.
CVS Health Compensation & Benefits Highlights
The following summarizes recurring compensation and benefits themes identified from responses generated by popular LLMs to common candidate questions about CVS Health and has not been reviewed or approved by CVS Health.
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Healthcare Strength — Health coverage includes medical, dental, and vision with HSA-eligible options, free preventive care, virtual care, and access to MinuteClinic services. Mental-health resources such as counseling support are emphasized, and coverage is often considered solid for full-time colleagues.
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Retirement Support — A dollar-for-dollar 401(k) match up to 5% after one year and an Employee Stock Purchase Plan are consistently highlighted in Total Rewards materials. Feedback suggests retirement programs are a meaningful strength within the overall package.
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Wellbeing & Lifestyle Benefits — Wellbeing offerings include up to 20 no-cost counseling sessions per issue, backup care, tuition assistance, and substantial in-store discounts, alongside broader wellness tools. These everyday perks expand value beyond base pay and can be especially meaningful for full-time schedules.
CVS Health Insights
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What We Do
CVS Health is the leading health solutions company that delivers care in ways no one else can. We reach people in more ways and improve the health of communities across America through our local presence, digital channels and our nearly 300,000 dedicated colleagues – including more than 40,000 physicians, pharmacists, nurses and nurse practitioners. Wherever and whenever people need us, we help them with their health – whether that’s managing chronic diseases, staying compliant with their medications, or accessing affordable health and wellness services in the most convenient ways. We help people navigate the health care system – and their personal health care – by improving access, lowering costs and being a trusted partner for every meaningful moment of health. And we do it all with heart, each and every day.
