Decision Scientist

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.

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.

• 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…