Certified Professional Coder | Audit & Compliance

Hispanic Alliance for Career Enhancement; Rhode Island; Hybrid; USD 43,888 - 93,574; Full time

Job summary

CVS Health is seeking a Certified Professional Coder (CPC) to perform medical claim reviews for the Special Investigations Unit (SIU). The role ensures coding accuracy and compliance by auditing CPT/HCPCS and modifiers against medical records.

You will discuss findings with investigators and regulators, identify billing errors and potential fraud, and maintain up-to-date knowledge of coding guidelines across CMS and payer requirements.

Qualifications

• AAPC CPC certification and 3+ years of medical coding or documentation auditing.
• Knowledge of CPT, HCPCS, ICD-10, CMS 1500 and UB04 data elements.
• Experience researching coding guidance and policies; proficient in Excel and Word.

Responsibilities

• Conduct medical record audits to verify CPT/HCPCS or modifiers align with documentation.
• Provide detailed written summaries of findings.
• Articulate findings to investigators, Medicaid leadership, law enforcement, counsel, providers, and regulators.
• Identify billing errors, potential fraud and opportunities for savings.
• Maintain records and follow workflows to meet metrics.
• Keep up-to-date coding knowledge.

Skills

CPC Certification

Medical coding experience

Attention to detail

Communication skills

Behavioral Health coding

Payor auditing experience

Education

GED or equivalent

CPC Certification

Tools

Excel

Word

Job description

CVS Health is seeking a Certified Professional Coder (CPC) to perform medical claim reviews for the Special Investigations Unit (SIU). The role ensures coding accuracy and compliance by auditing CPT/HCPCS and modifiers against medical records.

You will discuss findings with investigators and regulators, identify billing errors and potential fraud, and maintain up-to-date knowledge of coding guidelines across CMS and payer requirements.