Certified Professional Coder, Special Investigations Unit (Aetna SIU)
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About this role
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.
Position Summary
The Certified Professional Coder (CPC) will perform medical claim reviews 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.
Activities include:
- Conduct a comprehensive medical record review to ensure billing is consistent with medical record.
- 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.
- 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.
- Ability to travel for meetings and potential to testify
Required Qualifications
- AAPC Coding certification - Certified Professional Coder (CPC)
- 3+ years of experience in medical coding or documentation auditing.
- Strong knowledge of standard industry coding guides and guidelines including CPT, HCPCS, Revenue Codes, CMS 1500 and UB04 data elements
- Experience with researching coding, state regulations and policies.
- Working experience with Microsoft Excel
Preferred Qualifications
- 2 years or more previous experience with Behavioral Health coding/auditing of records
- Prior auditing experience
- Excellent analytical skills
- Excellent communication skills
- Strong attention to detail and ability to review and interpret data
Education
- GED or equivalent
- AAPC Certified Professional Coder Certification (CPC)
Anticipated Weekly Hours
40Time Type
Full timePay Range
The typical pay range for this role is:
$43,888.00 - $102,081.00This 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.
Company
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