Decision Analyst - SME, Medical Coding, Fraud Waste & Abuse Ideation

Bring your heart to CVS Health. Every one of us at CVS Health shares a single, clear purpose: Bringing our heart to every moment of your health. This purpose guides our commitment to deliver enhanced human-centric health care for a rapidly changing world. Anchored in our brand — with heart at its center — our purpose sends a personal message that how we deliver our services is just as important as what we deliver.
 
Our Heart At Work Behaviors™ support this purpose. We want everyone who works at CVS Health to feel empowered by the role they play in transforming our culture and accelerating our ability to innovate and deliver solutions to make health care more personal, convenient and affordable.

Position Summary

Position dedicated to supporting the Fraud, Waste & Abuse program within Analytics & Behavior Change. This candidate will be asked to drive growth opportunities for the program.  This candidate will own multiple projects, balance workstreams, and understand key business drivers for the team’s area of responsibility that will propel growth and delivery of solutions for specific business problems.

Identifies and researches program-specific issues, identifies solutions and leads resolution of issues working with internal business partners, clients, and external vendors.

Collaborates with Program Manager, Decision Scientists, and various other stakeholders to achieve operational and financial objectives. Needs to be able to work well independently, initiate strategic solutions, manage projects, and work collaboratively with the program team.

Primary Responsibilities:

• Understands key business drivers for own area of responsibility.
• Ability to communicate effectively with internal and external stakeholders.
• Can explain product vision and strategy to colleagues within A&BC, understands fully how product aligns with CVSH.
• Identifies appropriate data sources for analytics solutions.

• Conducts yearly monitoring of concept inventory to decision any necessary changes.
• Ability to analyze an issue or a need, review data, conduct research and initiate a solution.
• Ability to make decisions independently.
• Drive engagement with business partners.
• Ability to seek a solution to issues by collaborating with others.
• Ability to interact with Program Manager to solution and prioritize.
• Participates in presentations and consultations to clients on methods, specifications, and findings.
• Manages personal resources efficiently to complete assigned projects accurately and timely.
• Participates in the development of project plans and timelines.
• Responsible for commitments to quality and on-time deliverables.

Additional Candidate Requirements:

• Minimum of five years industry experience with health care claims Fraud, Waste, and Abuse claim processing, and claim platforms
• Proficient in QuickBase
• Ability to work independently
• Strong analytical and research skills
• Proficient in researching information and identifying information resources
• Detail-oriented
• Strong verbal and written communication skills
• Ability to interact with different groups of people at different levels
• Ability to utilize company systems to obtain relevant electronic documentation

Education and Experience:

• Preferred Bachelor’s degree or three years of equivalent experience in the industry
• 5+ years in claims processing knowledge and experience within ACAS, QNXT or HRP (HRP strongly preferred).
• Demonstrated written and verbal communication skills with the ability to present information to various audiences.
• Proficiency in Word, Excel, Database search tools, and the use of the Intranet/Internet to research information.
• Medical Coding Certificate

Education
 

• Preferred Bachelor’s degree or three years of equivalent experience in the industry

Pay Range

The typical pay range for this role is:

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  
 
In addition to your compensation, enjoy the rewards of an organization that puts our heart into caring for our colleagues and our communities.  The Company offers a full range of medical, dental, and vision benefits.  Eligible employees may enroll in the Company’s 401(k) retirement savings plan, and an Employee Stock Purchase Plan is also available for eligible employees.  The Company provides a fully-paid term life insurance plan