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The Certified Professional Coder (CPC) will perform medical claim reviews for the Special Investigations Unit (SIU) to ensure compliance with coding practices through a comprehensive record review for medical, behavioral, transportation and other healthcare providers. The CPC must have the ability to determine correct coding and appropriate documentation during the review of medical records. The CPC must also ensure that the state, federal and company requirements are met and recognize any concerning billing patterns or trends.

• Conduct a comprehensive medical record audit to ensure the CPT/HCPCS or modifiers billed are consistent with medical record documentation.

• Provide detailed written summary of medical record review findings.

• Must be able to articulate findings to investigators, Medicaid plan leadership, law enforcement, legal counsel, providers, state regulators, etc.

• Research and accurately apply state or CMS guidelines related to the audit with minimal support.

• Review and discuss cases with Medical Directors to validate decisions.

• Assist with investigative research related to coding questions, state and federal policies.

• Identify potential billing errors, abuse, and fraud.

• Identify opportunities for savings related to potential cases which may warrant a prepayment review.

• Maintain appropriate records, files, documentation, etc.

• Uses department resources regularly and follows workflows with minimal assistance or intervention to perform daily work to meet metrics.

• Maintains up-to-date coding knowledge, including new changes to coding compliance and reimbursement.

Required Qualifications

• AAPC Certified Professional Coder Certification (CPC)

• 3+ years of experience in medical coding or documentation auditing.

• Knowledge of standard industry coding guides and guidelines including CPT, HCPCS, ICD-10, CMS 1500 and UB04 data elements

• Experience with researching coding and policies.

• Experience with Microsoft products, specifically Excel and Word

Preferred Qualifications

• Strong attention to detail and ability to review and interpret data.

• Demonstrates strong communication skills.

• Prior auditing experience

• Excellent communication skills

• Excellent analytical skills

• Two years or more previous experience with Behavioral Health coding/auditing of records

Education

• AAPC Certified Professional Coder Certification (CPC)

Anticipated Weekly Hours

Time Type

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. 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.

Additional details about available benefits are provided during the application process and on Benefits Moments.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.