# Fraud, Waste, and Abuse (FWA) Analyst II **Company**: CVS Health **Location**: Work from home, FL **Work arrangement**: remote **Experience**: senior **Job type**: full-time **Salary**: $43,888.00 - $85,068.00 **Category**: Healthcare **Industry**: Healthcare **Apply**: https://cvshealth.wd1.myworkdayjobs.com/en-US/CVS_Health_Careers/job/FL---Work-from-home/Special-Investigation-Unit-Lead-Review-Analyst-II--Aetna-SIU-_R1063972?utm_source=yubhub.co&utm_medium=jobs_feed&utm_campaign=apply **Canonical**: https://yubhub.co/jobs/job_56d8070e-921 ## Description We're building a world of health around every individual , shaping a more connected, convenient and compassionate health experience. The Fraud, Waste, and Abuse (FWA) Analyst II identifies and develops potential healthcare fraud leads through data mining, claims analysis, and investigative research. **Lead 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, utilisation 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. **Data Analysis & Research** - Perform detailed quantitative and qualitative analysis of medical and pharmacy claims data. - Analyse CPT, HCPCS, ICD, DRG, NDC, modifier usage, and reimbursement trends. - Review provider billing history, peer comparisons, utilisation metrics, and financial impact analyses. - Conduct research utilising internal systems, external public records, licensing boards, sanctions lists, and other investigative resources. - Analyse relationships among providers, members, facilities, and associated entities to identify potential schemes or collusive activity. **Case Evaluation & Recommendations** - 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. **Collaboration & Operational Support** - 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. **Compliance & Quality** - Ensure all activities comply with CMS, state Medicaid regulations, Medicare requirements, organisational 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, Power BI, 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 organisational and time-management abilities with the capability to manage multiple priorities. - Bilingual in English/Spanish. **Education** - Bachelor's degree or equivalent combination of education and experience. **Anticipated Weekly Hours** 40 **Time Type** Full time **Pay Range** $43,888.00 - $85,068.00 ## Skills ### Required - healthcare data analysis - claims analysis - auditing - payment integrity - healthcare fraud experience - analytical skills - critical thinking - problem-solving - Spanish ### Nice to have - 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, Power BI, or equivalent analytical platforms - Certified Fraud Examiner (CFE), Accredited Healthcare Fraud Investigator (AHFI), Certified Professional Coder (CPC) --- Source: [Apply at cvshealth.wd1.myworkdayjobs.com](https://cvshealth.wd1.myworkdayjobs.com/en-US/CVS_Health_Careers/job/FL---Work-from-home/Special-Investigation-Unit-Lead-Review-Analyst-II--Aetna-SIU-_R1063972?utm_source=yubhub.co&utm_medium=jobs_feed&utm_campaign=apply)