Special Investigation Unit Lead Review Analyst II (Aetna SIU)

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 Fraud, Waste, and Abuse (FWA) Analyst II identifies and develops potential healthcare fraud leads through data mining, claims analysis, and investigative research. As a key contributor to the SIU lead development process, this role evaluates provider, member, pharmacy, and ancillary healthcare billing patterns for signs of fraud, waste, abuse, and other anomalies. The Analyst II uses internal claims data, analytical tools, business rule results, and industry intelligence to assess potential FWA concerns and determine whether they warrant formal investigation. This role requires strong analytical skills, healthcare claims expertise, and the ability to translate complex data into actionable investigative leads and recommendations. Essential Responsibilities 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, utilization 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. • Analyze CPT, HCPCS, ICD, DRG, NDC, modifier usage, and reimbursement trends. • Review provider billing history, peer comparisons, utilization metrics, and financial impact analyses. • Conduct research utilizing internal systems, external public records, licensing boards, sanctions lists, and other investigative resources. • Analyze 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, organizational policies, and SIU procedures. • Maintain confidentiality and safeguard sensitive information. • Meet departmental productivity, quality,