Special Investigation Unit Lead Review Analyst (Aetna SIU)

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. 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 • 3-5 years of data interpretation and analysis experience. • Healthcare background. • Excellent verbal and written communication skills. • Experience with healthcare coding • Must be able to travel to provide testimony if needed • Advanced experience with Excel Preferred Qualifications • A solid understanding of medical and pharmaceutical claim data, medical claims coding (CPT/ICD/NDC), Aetna clinical and payment policies, as well as core Aetna systems (QNXT, ACAS, EWM, EPDB, IOP). • Some experience using Tableau is a plus. • Previous healthcare fraud experience • Experience with Aetna clinical and payment policies • Certified Professional Coder (CPC) certification is a plus • Medicaid Experience Education • Bachelor's degree 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 - $76,500.00 This 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 our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include: • 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. For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will close on: 11/11/2025 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. Apply tot his job Apply To this Job