Decision Scientist

The Decision Scientist supports Payment Integrity, Special Investigations Unit (SIU), Analytics & Behavior Change (A&BC), and Clinical Policy initiatives through advanced analytics, opportunity identification, and business rule development. This role transforms complex healthcare data into actionable insights that drive affordability, strengthen fraud, waste, and error (FWE) detection, and improve operational performance. The Decision Scientist collaborates with cross-functional stakeholders to evaluate opportunities, develop analytical solutions, validate business rules, and deliver measurable business value., 1. Ideation Management and Opportunity Development

• 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.

1. Clinical and Healthcare Subject Matter Expertise * 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.

2. Advanced Analytics and Business Rule Development * 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.

3. Technical Review and Quality Assurance * 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.

4. Communication and Recommendations * 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.

5. Strategic Business Collaboration * 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.

6. Continuous Improvement and Innovation * 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.

• 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

Preferred Qualifications

• 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.

Core Competencies

• 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.

Education

• Bachelor’s degree in Business Analytics, Data Science, Healthcare Administration, Statistics, Economics, Nursing, Health Information Management, or a related field preferred.
• Equivalent combination of education and relevant work experience considered.

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. This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above.

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.

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.