[Remote] Decision Scientist

Note: The job is a remote job and is open to candidates in USA. CVS Health is a healthcare company focused on creating a more connected, convenient, and compassionate health experience. The Decision Scientist supports Payment Integrity, Special Investigations Unit, Analytics & Behavior Change, and Clinical Policy initiatives by applying advanced analytics, developing business rules, identifying opportunities, and translating healthcare data into actionable recommendations.

Responsibilities

• Facilitate the intake, assessment, prioritization, and tracking of affordability, fraud, waste, error, and Payment Integrity opportunities
• Conduct preliminary assessments, business case development, and value estimation activities for potential concepts
• Maintain ideation inventories and support documentation to ensure transparency and progress tracking
• Quantify opportunity value, implementation complexity, and projected business impact to support prioritization decisions
• Collaborate with stakeholders to advance ideas from concept through evaluation and implementation
• Apply healthcare industry knowledge, coding expertise, and policy interpretation to support the identification and evaluation of fraud, waste, error, and payment integrity risks
• Utilize clinical knowledge to help interpret billing patterns, evaluate medical necessity, and ensure analytical approaches aligned with enterprise policy, healthcare industry standards and regulatory requirements
• Conduct exploratory, descriptive, predictive, and diagnostic analyses using claims, provider, member, and operational data
• Develop, test, and refine business rules, algorithms, and analytical methodologies that identify emerging fraud, waste, error, and payment integrity risks
• Partner with business stakeholders to translate operational challenges into analytical solutions
• Validate analytical outputs and detection methodologies to optimize effectiveness while minimizing false positives
• Measure and report business impact associated with implemented solutions
• Perform quality review and validation of analytical methodologies, business rules, and technical implementations to ensure accuracy, consistency, and operational effectiveness
• Collaborate with technical teams to ensure analytical solutions are accurately implemented, validated, and maintained throughout the development lifecycle
• Analyze and synthesize complex analytical results into meaningful and actionable information for investigators, business partners, and leadership
• Communicate findings in a clear and concise manner that supports informed decision-making, operational improvements, and strategic planning
• Develop evidence-based recommendations that improve investigative outcomes, strengthen fraud detection capabilities, reduce financial losses, and enhance operational efficiency
• Support stakeholders in evaluating risks, opportunities, and potential impacts associated with proposed actions
• Build strong partnerships across SIU, FWE, payment integrity, compliance, clinical operations, and other business areas to understand strategic priorities and organizational objectives
• Collaborate to design analytical solutions that align with enterprise goals, improve program integrity, and deliver measurable business value
• Influence cross-functional stakeholders by balancing business objectives, operational feasibility, regulatory requirements, and financial impact
• Identify opportunities to enhance analytical methodologies, business rules, and investigative processes through automation and advanced analytics
• Evaluate new data sources, AI-enabled capabilities, and emerging technologies to improve detection effectiveness and operational efficiency
• Leverage automation, AI-enabled tools, and emerging analytical techniques to improve scalability, productivity, and detection effectiveness

Skills

• Minimum 3 years of experience in clinical coding, clinical consulting, healthcare auditing/analytics, or related analytical functions in claim systems such as ACAS, QNXT, HRP
• Experience developing business rules, performing trend analysis, and identifying program improvement opportunities
• Experience with SAS, SQL, Python, R, or other analytical programming tools and analyze large healthcare datasets
• Experience applying statistical analysis, trend identification, or predictive methodologies to solve business problems
• Ability to translate complex data findings into actionable business recommendations
• Demonstrated ability to communicate clinical and analytical concepts to technical and non-technical audiences
• Strong project management and organizational skills
• Experience developing business cases and quantifying financial impact
• Strong analytical, critical-thinking, and problem-solving skills
• Ability to quantify financial opportunity and evaluate return on investment (ROI)
• Ability to communicate analytical findings through compelling narratives, visualizations, and executive presentations
• Ability to connect tactical analytics work to enterprise affordability and payment integrity objectives
• Curiosity and willingness to challenge existing processes through data-driven recommendations
• Ability to independently manage multiple priorities in a fast-paced environment
• Strong attention to detail and commitment to quality
• Excellent written, verbal, and presentation communication skills
• Ability to influence and collaborate with cross-functional stakeholders
• Strong business acumen with the ability to connect analytical findings to operational and financial outcomes
• Equivalent combination of education and relevant work experience considered
• Certified Professional Coder (CPC)
• Accredited Healthcare Fraud Investigator (AHFI®)
• Experience supporting SIU investigations and FWE programs
• Experience with predictive analytics, AI-assisted analytics, or machine learning methodologies
• Experience with machine learning, artificial intelligence, or anomaly detection techniques
• Experience developing dashboards using Power BI, Tableau, or similar visualization tools
• Bachelor's degree in Business Analytics, Data Science, Healthcare Administration, Statistics, Economics, Nursing, Health Information Management, or a related field preferred

Benefits

• 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.
• Medical, dental, and vision coverage
• Paid time off
• Retirement savings options
• Wellness programs
• Other resources, based on eligibility
• CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above

Company Overview

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