Special Investigation Unit Lead Review Analyst in Ok Work From Home

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. Moni