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Position SummaryThe Fraud, Waste, and Abuse (FWA) Analyst II identifies and develops potential healthcare fraud leads through data mining, claims analysis, and investigative research. As a key contributor to the SIU lead development process, this role evaluates provider, member, pharmacy, and ancillary healthcare billing patterns for signs of fraud, waste, abuse, and other anomalies.
The Analyst II uses internal claims data, analytical tools, business rule results, and industry intelligence to assess potential FWA concerns and determine whether they warrant formal investigation. This role requires strong analytical skills, healthcare claims expertise, and the ability to translate complex data into actionable investigative leads and recommendations.
Essential ResponsibilitiesLead Development & Fraud Detection
- 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 leads generated by business rules to assess their credibility and investigative value.
- Examine spike analyses, utilization trends, payment anomalies, and outlier reports for unusual billing patterns.
- Evaluate provider, member, pharmacy, DME, transportation, and facility billing for indicators of fraud or abuse.
- Monitor internal and external intelligence sources to detect emerging fraud schemes and patterns.
- Perform detailed 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.
- Conduct research utilizing internal systems, external public records, licensing boards, sanctions lists, and other investigative resources.
- Analyze relationships among providers, members, facilities, and associated entities to identify potential schemes or collusive activity.
- Develop comprehensive lead summaries outlining allegations, supporting evidence, and identified risk indicators.
- Present analytical findings and recommendations to SIU leadership and investigative staff.
- Determine whether findings support escalation to a formal investigation, monitoring activity, or closure.
- Document investigative rationale and supporting evidence in accordance with SIU policies and regulatory requirements.
- Provide actionable recommendations based on analytical findings and business intelligence.
- Partner with investigators, clinicians, legal, compliance, and business partners regarding potential FWA concerns.
- Participate in fraud trend discussions and special projects aimed at strengthening fraud detection efforts.
- Support continuous improvement initiatives involving business rules, data mining strategies, and lead generation methodologies.
- Assist with training and knowledge related to emerging fraud schemes and healthcare billing practices.
- Ensure all activities comply with CMS, state Medicaid regulations, Medicare requirements, organizational policies, and SIU procedures.
- Maintain confidentiality and safeguard sensitive information.
- Meet departmental productivity, quality, and timeliness standards.
- Support internal audits, quality reviews, and regulatory reporting activities.
Required Qualifications
- 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%
Preferred Qualifications
- 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, SQL, JIRA, Power BI, SAS, 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.
Education
- Bachelor's degree or equivalent combination of education and experience.
Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$43,888.00 - $93,574.00This 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.
Skills Required
- 3+ years of healthcare data analysis, SIU, claims analysis, auditing, payment integrity, or healthcare fraud experience
- Strong analytical and critical-thinking skills
- 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
- 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, SQL, JIRA, Power BI, SAS, or equivalent analytical platforms
- Certified Fraud Examiner, Accredited Healthcare Fraud Investigator, Certified Professional Coder, or similar certification
- Excellent verbal, written, and presentation skills
- Strong organizational and time-management abilities with the capability to manage multiple priorities
- Bachelor's degree or equivalent combination of education and experience
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
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.
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