• Job Description

  Req#: R0861300
  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
  40
  
  Time Type
  Full time
  
  Pay Range
  
  The typical pay range for this role is:
  
  $46,988.00 - $112,200.00
  
  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 offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families.
  
  This full-time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well-being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.
  
  Additional details about available benefits are provided during the application process and on Benefits Moments.
  
  We anticipate the application window for this opening will close on: 05/11/2026
  
  Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.

• About the company

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