Special Investigation Unit Lead Review Analyst (Aetna SIU)

Special Investigations Unit

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 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.

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 :

For more information, visit https : / / jobs.cvshealth.com / us / en / benefits

We anticipate the application window for this opening will close on : 01 / 03 / 2026 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. We are an equal opportunity and affirmative action employer. We do not discriminate in recruiting, hiring, promotion, or any other personnel action based on race, ethnicity, color, national origin, sex / gender, sexual orientation, gender identity or expression, religion, age, disability, protected veteran status, or any other characteristic protected by applicable federal, state, or local law.