Special Investigation Unit (SIU) Manager

The Certified Professional Coder (CPC) Manager will oversee a team of medical coders within the Special Investigations Unit (SIU) to ensure compliance with coding practices through comprehensive record reviews for medical, behavioral, transportation, and other healthcare providers. Role Overview Lead and mentor a team of CPCs, providing training, guidance, and support in coding practices and medical record reviews. Conduct regular audits of team performance to ensure compliance with CPT/HCPCS coding and documentation standards. Establish team goals, monitor performance, and ensure alignment with organizational objectives. Direct and oversee complex coding reviews and resolve intricate issues with sensitivity, including claim reviews for legal, compliance, or rework projects. Ensure staff provide detailed written summaries of medical record review findings and ensure the team articulates findings effectively to investigators, Medicaid plan leadership, law enforcement, legal counsel, providers, and state regulators. Conduct team member evaluations and provide performance feedback to staff on an ongoing basis. Collaborate with Medical Directors to validate decisions and discuss complex cases. Manage workload of the team to ensure equitable distribution and exposure to a wide range of cases to match current skills and development needs. Assist with investigative research related to coding questions, state and federal policies, and identify potential billing errors, abuse, and fraud. Identify opportunities for savings related to potential cases that may warrant a prepayment review. Maintain appropriate records, files, and documentation for the team. Utilize department resources effectively and ensure workflows are followed to meet performance metrics. Collaborate with investigators, data analytics, and plan leadership on SIU schemes and initiatives. Act as the primary point of contact for the team in the absence of the director, ensuring continuity of operations and support. Develop and implement training and onboarding programs for new team members. Requirements AAPC Coding certification. 5+ years of experience in medical coding or documentation auditing. Strong knowledge of standard industry coding guides and guidelines, including CPT, HCPCS, ICD-10, CMS 1500, and UB04 data elements. Maintains up-to-date coding knowledge, including new changes to coding compliance and reimbursement. Experience with researching coding and policies. 3+ years in a leadership role required. Proficiency in Microsoft products, particularly Excel and Word. Strong attention to detail and ability to review and interpret data. Demonstrates strong communication and leadership skills. Prior auditing experience is preferred. Excellent analytical skills and the ability to mentor and develop team members. Anticipated Weekly Hours: 40 Time Type: Full time Pay Range $54,300.00 - $159,120.00 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. Benefits 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. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. #J-18808-Ljbffr CVS Health