Special Investigation Unit Lead Review Analyst II (Aetna SIU)
Core
Identify and develop healthcare fraud, waste, and abuse leads through data mining, claims analysis, and investigative research to determine if they warrant formal investigation.
Role type
Senior IC healthcare fraud analyst (SIU lead development)
Builds
Actionable investigative leads and recommendations for the Special Investigation Unit
Domain
Healthcare insurance / Payment integrity / Fraud detection
Deliverable
production ML models | product features | dashboards & analysis | client delivery
Required skills
Healthcare claims analysis, Data mining, Anomaly detection, CPT/HCPCS/ICP/DRG/NDC coding knowledge, Provider billing pattern analysis, Regulatory compliance (CMS/Medicare/Medicaid), Critical thinking, Trend analysis, Case documentation
Preferred skills
SIU experience, Medicare/Medicaid/Commercial program knowledge, Fraud detection tool usage, Business rule engine familiarity, Tableau/SQL/Power BI/SAS proficiency, CFE/AHFI/CPC certification
Technologies
Tableau, SQL, JIRA, Power BI, SAS, Business rule engines, Investigative case management systems
Responsibilities
Mine claims databases and reporting tools to generate FWA leads, Validate and refine leads from business rules, Analyze utilization trends and payment anomalies, Research provider history and external sanctions lists, Develop lead summaries with evidence and risk indicators, Partner with investigators and legal teams on FWA concerns
Seniority
Mid-Senior, hands-on IC