SIU Medical & Behavioral Health Coding Analyst

Certified Professional Coder (Cpc)

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 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 review to ensure the CPT/HCPCS/Revenue codes and/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, plan leadership, law enforcement, legal counsel, providers, state regulators, etc.

Research and accurately apply state or CMS guidelines related to the review 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 CPC certification

Minimum of 3 years of experience in medical and/or behavioral health professional coding, with at least 1-2 years of current professional coding experience, including medical record review and documentation auditing.

Knowledge of professional medical coding systems, including CPT, HCPCS, and Revenue Codes.

CMS 1500 and UB04 data elements.

Demonstrated ability to interpret, apply, and consistently apply established coding policies and guidelines.

Experience with Microsoft products; Excel and Word.

Ability to travel for the role, if needed.

Preferred Qualifications

CPMA certification

Credentials such as certification from the Association of Certified Fraud Examiners (CFE) or an accreditation from the National Health Care Anti-Fraud Association (AHFI).

Experience performing coding and audit functions within a health plan or payer environment.

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

Demonstrates strong written and verbal communication skills.

Education

AAPC Certified Professional Coder Certification (CPC).

GED or High School diploma.

Anticipated Weekly Hours: 40

Time Type: Full time

Pay Range: $43,888.00 - $93,574.00

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.

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.