Program Integrity Auditor

Program Integrity Auditor

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 Program Integrity Auditor is responsible for the review of records for medical, behavioral, transportation, and other healthcare providers. The Auditor must have the ability to determine correct coding and appropriate documentation during the review of medical records. Activities include reviews/audits of provider records to ensure appropriate coding standards and documentation standards are being met. The Auditor will also be recommending follow-up action including (but not limited to) provider education, recoupment of funds or rebilling of claims, and referral to state regulators for any suspected fraud, waste, or abuse (FWA). The Auditor must also ensure that state and federal requirements are met and recognize any concerning billing patterns or trends.

Primary Responsibilities

• Serve as an audit team member for a health plan(s) which currently administers benefits to Medicaid members across multiple lines of business including acute, behavioral health, individuals with developmental disabilities, and children in out-of-home care.
• Audit records on a routine basis, as well as records for audits (requested on an ad hoc basis) for all lines of business, in order to ensure coding and documentation meet regulatory standards. These may include (but are not limited to) appropriate code usage, appropriate modifier usage, appropriate place of service usage, etc.
• Coordinate audit documentation and reports for review for internal and external staff and stakeholders.
• Identify aberrant billing patterns and potential FWA, reporting this to internal staff. Assisting with further investigation and/or reports to state regulators through the utilization of developed critical thinking skills.
• Assist with the development and implementation plan for prospective and retrospective FWA avoidance, detection, and referral.
• Assist with the creation and submission of regulator deliverables through completion of timely audit activities.
• Provide technical assistance and education to providers including training on regulatory requirements, as well as coding and documentation rules.
• Maintain compliance with company policies and procedures.
• Perform other duties as assigned.

Required Qualifications

• 3-5 years of experience in reviewing and interpreting claims data, as well as medical records and appropriate documentation.
• 3-5 years of experience with standard industry coding guidelines such as CPT, HCPCs, and ICD-10.
• Willingness to work Monday-Friday from 8am-5pm 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 presentational skills.
• Strong communication skills, both written and verbal.
• Ability to be adaptable 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

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.

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.