Special Investigation Unit Lead Review Analyst II (Aetna SIU)
for section headings: About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule. But we should only include sections when posting has real specific content. We need to map content.
We have:
- About the role: The mission paragraph and Position Summary could be considered "About the role". We'll put that in a section with heading About the role
and then
containing the mission and position summary. - Responsibilities: The Essential Responsibilities (Lead Development & Fraud Detection, Data Analysis & Research, Case Evaluation & Recommendations, Collaboration & Operational Support, Compliance & Quality). Actually Collaboration & Operational Support and Compliance & Quality are sub-sections but could be part of responsibilities. We'll combine them under Responsibilities. We need to use
- for any list of duties/requirements/benefits. So we need to list each bullet as
- . The responsibilities have multiple bullet points under each subheading. We'll flatten them into a list.
- Requirements: Could be Required Qualifications? The spec says headings: Requirements, Qualifications, Skills, Benefits, Pay, Schedule. We have Required Qualifications, Preferred Qualifications, Education, etc. We need to decide mapping.
We have "Required Qualifications" (3+ years experience, analytical skills, etc.) and "Preferred Qualifications" (experience in SIU, knowledge of programs, etc.), Education (Bachelor's degree). Also "Anticipated Weekly Hours 40", "Time Type Full time", "Pay Range". Benefits described.
We need to avoid filler like "commensurate with experience". Not present.
We need to include Pay section only if posting states it: yes, Pay Range given. So include
Pay
withcontaining the pay range details. Schedule: we have Anticipated Weekly Hours 40, Time Type Full time. That's schedule info. So include
Schedule
withcontaining those details. Benefits: we have benefits description. Include
Benefits
withdescribing benefits. Skills: maybe we can include under Qualifications? But we have a separate Skills heading. Could we put skills from Required/Preferred qualifications under Skills? The spec says we can use Skills heading if there is real specific content. We have skills like analytical, critical-thinking, interpreting large datasets, knowledge of coding, etc. Could create a Skills section. But we also have Required Qualifications and Preferred Qualifications. Might be better to combine qualifications into Requirements and Qualifications sections. The spec says we can have Requirements, Qualifications, Skills. We need to decide. We have Required Qualifications (mandatory) and Preferred Qualifications (nice-to-have). Education also. We could map: - Requirements: Required Qualifications (mandatory) + Education? Or maybe Requirements = Required Qualifications. - Qualifications: Preferred Qualifications. - Skills: maybe we can extract skill statements from both required and preferred (analytical skills, knowledge of coding, experience with tools, certifications). But we risk duplication. Better to follow spec: Use headings only when posting has real specific content. We have content for: - About the role - Responsibilities - Requirements (Required Qualifications) - Qualifications (Preferred Qualifications) - Benefits - Pay - Schedule We could also add Skills if we want, but we already have Required and Preferred qualifications covering skills. Might be thin but still specific. However spec says prefer a few substantive sections over many thin ones. So maybe we omit Skills and put skill details within Requirements/Qualifications. Thus sections: About the role, Responsibilities, Requirements, Qualifications, Benefits, Pay, Schedule. We need to ensure we don't repeat job title as heading. Not needed. We must not include boilerplate like EEO, application instructions, etc. Remove lines about application window closing, arrest records, etc. Also remove "Our people fuel our future..." etc? That's boilerplate about benefits? Actually that's part of benefits intro but could be considered boilerplate. The spec says remove cookie/navigation/legal/EEO/equal-opportunity/scam-warning boilerplate, duplicated lines, and application instructions. The "Our people fuel our future..." is more of a generic statement but not explicitly listed as boilerplate; but it's part of benefits description. Might keep as it's part of benefits. However the benefits paragraph includes "Our people fuel our future..." which is generic fluff. Might be considered boilerplate? Not sure. Safer to keep benefits description but maybe trim that sentence. The spec says preserve ALL substantive information; do NOT invent or summarize away detail. So we should keep it if it's in the posting. It's not explicitly listed as boilerplate to remove. So keep. We need to output only HTML fragment. Let's extract content. About the role: Combine first paragraph and Position Summary. First paragraph: "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." We'll combine into a paragraph. Responsibilities: List all bullet points under Essential Responsibilities, Data Analysis & Research, Case Evaluation & Recommendations, Collaboration & Operational Support, Compliance & Quality. Let's extract each bullet: 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, and timeliness standards. - Support internal audits, quality reviews, and regulatory reporting activities. We'll put all these as
- items. Requirements (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%. Qualifications (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, SQL, JIRA, Power BI, SAS, 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 with the capability to manage multiple priorities. Education: Bachelor's degree or equivalent combination of education and experience. We could include Education under Requirements or Qualifications? But we have separate Education line. Could incorporate into Requirements as a bullet. However spec says we can have Requirements heading; we could include education there. But we already have Required Qualifications. Might be better to keep Education as part of Requirements (since it's a qualification). But we already have Required Qualifications heading; we could rename to Requirements and include both experience and education. However the spec says we can use Requirements heading for any list of duties/requirements/benefits. So we can put Required Qualifications + Education under Requirements. But we also have Preferred Qualifications; we could put under Qualifications. Thus: Requirements: list of required qualifications + education. Qualifications: list of preferred qualifications. We need to avoid duplication: education bullet appears only there. Now Benefits: The paragraph: "Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great Benefits For Great People We take pride in offering a comprehensive and competitive mix of pay and benefits that reflects our commitment to our colleagues and their families. This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility. Additional details about available benefits are provided during the application process and on Benefits Moments." We need to remove application instructions? The line "Additional details about available benefits are provided during the application process and on Benefits Moments." is about application process; maybe considered application instructions? It's not exactly instruction to apply, but mentions application process. The spec says remove application instructions. This line is about where details are provided; could be considered application instructions. Safer to remove that sentence. Keep the rest. Thus benefits paragraph: "Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great Benefits For Great People We take pride in offering