Coding Data Quality Auditor

Description 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 themselves 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 Program Integrity Auditor is responsible for reviewing records of medical, behavioral, transportation, and other healthcare providers. The auditor must determine correct coding and appropriate documentation during the review of medical records. Activities include audits of provider records to ensure coding and documentation standards are met, recommending follow‑up action (e.g., provider education, recoupment of funds or rebilling of claims), and referring suspected fraud, waste or abuse to state regulators. The auditor must also ensure state and federal requirements are met and recognize concerning billing patterns or trends. Primary Responsibilities Serve as an audit team member for a health plan that administers benefits to Medicaid members across multiple lines of business, including acute care, behavioral health, developmental disabilities, and children in out‑of‑home care. Audit records on a routine basis and on an ad hoc basis to ensure coding and documentation meet regulatory standards, such as appropriate code usage, modifier usage, and place of service usage. Coordinate audit documentation and reports for internal and external review. Identify aberrant billing patterns and potential FWA, reporting to internal staff and assisting with investigations and reports to state regulators. Assist with the development and implementation of plans for prospective and retrospective FWA avoidance, detection, and referral. Assist with the creation and submission of regulator deliverables by completing timely audit activities. Provide technical assistance and education to providers, including training on regulatory requirements and coding and documentation rules. Maintain compliance with company policies and procedures. Perform other duties as assigned. Required Qualifications 3–5 years of experience reviewing and interpreting claims data, medical records, and documentation. 3–5 years of experience with standard industry coding guidelines such as CPT, HCPCS, and ICD‑10. Willingness to work Monday‑Friday, 8 am–5 pm Arizona Time Zone. Must possess an active CPC (Certified Professional Coder), CCS (Certified Coding Specialist), or CPMA (Certified Professional Medical Auditor) license. Preferred Qualifications Previous auditing experience. Previous Medicaid and/or health plan experience, including AHCCCS (Arizona Health Care Cost Containment System). Previous experience with QuickBase. Strong analytical and critical thinking skills. Strong attention to detail. Ability to collaborate and work with a team, as well as work independently as needed. Excellent presentation skills. Strong communication skills, both written and verbal. Adaptability in a flexible environment. Education Associate’s degree or equivalent experience (2+ years of relevant experience + high school diploma or GED). Anticipated Weekly Hours 40 Time Type Full time Pay Range The typical pay range for this role is $46,988.00 – $122,400.00. The actual base salary offer will depend on experience, education, geography and other factors. This position is eligible for a CVS Health bonus, commission or short‑term incentive program in addition to the stated base pay range. Benefits This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of employees and their families. Benefits include medical, dental, and vision coverage; paid time off; retirement savings options; wellness programs; and other resources, based on eligibility. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws. #J-18808-Ljbffr