Special Investigation Unit Lead Review Analyst II (Aetna SIU)
Core
Identify and develop potential healthcare fraud leads through data mining, claims analysis, and investigative research to evaluate billing patterns for anomalies.
Role type
Senior IC healthcare fraud analyst (lead development)
Builds
Actionable investigative leads and recommendations for the Special Investigation Unit (SIU)
Domain
Healthcare / Insurance Fraud Detection
Required skills
Healthcare claims analysis, Data mining, Fraud detection, Claims coding (CPT, HCPCS, ICD, DRG, NDC), Anomaly detection, Regulatory compliance (CMS/Medicare/Medicaid), Investigative research, Data visualization (Tableau/Power BI)
Preferred skills
SIU experience, Medicare/Medicaid program knowledge, Fraud detection tools, Bilingual (English/Spanish), CFE/AHFI/CPC certification
Technologies
Tableau, Power BI, Business rule engines, Investigative case management systems, Claims databases
Responsibilities
Mine claims databases to generate FWA leads, Validate leads from business rules, Analyze utilization trends and payment anomalies, Research provider billing history and external records, Develop lead summaries with evidence, Present findings to SIU leadership, Ensure compliance with CMS and state regulations
Seniority
Mid-Senior, hands-on IC