Special Investigation Unit Lead Review Analyst (Aetna SIU)

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.

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, 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 :

Preferred Qualifications :

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. 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 :