Position SummaryThe Lead, Senior Decision Scientist serves as a strategic analytics and ideation leader supporting Payment Integrity Affordability initiatives with a primary focus on Fraud, Waste & Error (FWE) and Special Investigations Unit (SIU) programs. This role provides leadership and guidance to a team of Decision Scientists while driving the development, evaluation, and implementation of innovative opportunities that improve affordability outcomes and strengthen Payment Integrity capabilities.
The Lead Decision Scientist is responsible for establishing analytical frameworks, managing ideation pipelines, defining success metrics, and identifying cross-functional opportunities that create enterprise value across Payment Integrity programs.
Required Qualifications- 7+ years of experience in healthcare analytics, Payment Integrity, Fraud, Waste & Error (FWE), Special Investigations, or related healthcare operations.
- 5+ years of experience leading analytical projects or providing technical leadership within a healthcare environment.
- Demonstrated experience working with healthcare claims platforms including ACAS, QNXT, HRP, or comparable systems.
- Experience using SAS, SQL, Python, R, or other analytical and statistical programming languages.
- Experience performing advanced data analysis, opportunity identification, trend analysis, and business case development.
- Strong understanding of healthcare reimbursement methodologies, coding principles, and Payment Integrity programs.
- Proven ability to communicate complex analytical findings to both technical and non-technical audiences.
Responsibilities:
Leadership & Team Development- Provide day-to-day leadership, coaching, and mentorship to Decision Scientists while fostering a culture of innovation, collaboration, and accountability.
- Assist leadership with recruitment, interviewing, onboarding, training, and development of team members.
- Monitor workload prioritization and ensure timely progression of ideation concepts from intake through implementation.
- Establish and monitor performance expectations, project milestones, and quality standards for analytical deliverables.
Strategic Partnership & Innovation- Partner with internal business teams including Special Investigations Unit (SIU), Analytics & Behavior Change (A&BC), Clinical Policy, Medical Economics, and Payment Integrity leaders to identify affordability and program improvement opportunities.
- Lead the intake, evaluation, prioritization, and governance of affordability and ideation opportunities.
- Identify emerging risks, trends, and operational challenges and recommend data-driven solutions.
- Develop long-term measurement frameworks and success metrics to evaluate ideation outcomes and business value realization.
- Identify synergies and scalability opportunities across Payment Integrity programs and initiatives.
Analytics & Decision Science- Consult business partners to understand strategic goals, operational challenges, and analytical requirements.
- Analyze complex healthcare, claims, provider, and investigative data to identify patterns, trends, anomalies, and opportunities.
- Research, manipulate, and prepare large-scale datasets using statistical and analytical techniques.
- Develop integrated analytic datasets, dashboards, reports, studies, and predictive analyses to support business decision-making.
- Collaborate with Data Scientists, Medical Directors, Medical Economics, Payment Integrity, and Investigative teams to refine analytical methodologies and solution effectiveness.
- Evaluate the effectiveness of implemented opportunities and recommend iterative improvements.
- Present analyses and recommendations to leaders and stakeholders across multiple organizational levels.
Innovation & Ideation Leadership- Lead ideation sessions and facilitate opportunity-generation activities across stakeholder groups.
- Develop business cases and value assessments supporting affordability opportunities.
- Maintain ideation governance processes including intake, prioritization, tracking, and outcome measurement.
Communication- Develop executive-ready presentations and recommendations for senior leadership.
- Communicate analytical findings, risks, opportunities, and implementation considerations to decision-makers.
AI & Advanced Analytics- Evaluate emerging analytical methodologies, automation opportunities, and AI-enabled solutions that support Payment Integrity objectives.
- Identify opportunities to enhance analytical efficiency through advanced tools, automation, and predictive modeling.
Preferred Qualifications- Accredited Healthcare Fraud Investigator (AHFI®) Certification
- Certified Professional Coder (CPC) certification
- Strong analytical problem-solving and critical-thinking skills.
- Demonstrated ability to perform independent research and translate findings into actionable recommendations.
- Excellent written, verbal, and presentation communication skills.
- Strong attention to detail and organizational skills.
- Ability to influence stakeholders and build collaborative partnerships across multiple functions.
- Experience utilizing enterprise data sources, investigative tools, and healthcare analytics platforms.
- Working knowledge of Aetna/CVS Health policies, procedures, and Payment Integrity operations preferred.
Education- Bachelor's degree in Business Analytics, Data Science, Healthcare Administration, Statistics, Economics, Computer Science, or a related field; equivalent combination of education and experience considered.
Anticipated Weekly Hours40
Time TypeFull time
Pay RangeThe typical pay range for this role is:
$92,700.00 - $222,480.00
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.
Great benefits for great peopleWe 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.
Additional details about available benefits are provided during the application process and on Benefits Moments.
We anticipate the application window for this opening will close on: 09/26/2026
