Special Investigation Unit Lead Review Analyst II (Aetna SIU)

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.

Responsibilities

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; Examine spike analyses, utilization trends, payment anomalies, and outlier reports; 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; 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 using internal systems, public records, licensing boards, sanctions lists, and other investigative resources; Analyze relationships among providers, members, facilities, and associated entities; Develop comprehensive lead summaries outlining allegations, evidence, and risk indicators; Present analytical findings and recommendations to SIU leadership and investigative staff; Determine whether findings support escalation to formal investigation, monitoring, or closure; Document investigative rationale in accordance with SIU policies and regulatory requirements; Partner with investigators, clinicians, legal, compliance, and business partners; Participate in fraud trend discussions and special projects; Support continuous improvement of business rules, data mining strategies, and lead generation methodologies; Assist with training on emerging fraud schemes and healthcare billing practices; Ensure compliance with CMS, state Medicaid, Medicare requirements, organizational 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

Requirements

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%; Bachelor's degree or equivalent combination of education and experience

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), or similar certification; Excellent verbal, written, and presentation skills; Strong organizational and time-management abilities; Bilingual in English/Spanish

Benefits

Medical, dental, and vision coverage; Paid time off; Retirement savings options; Wellness programs; Eligibility for CVS Health bonus, commission or short-term incentive program