CPC Medical Coding Investigator – SIU & Behavioral Health

Preferra Insurance; Raleigh (NC); Hybrid; USD 44,000 - 94,000; Full time

Job summary

CVS Health is seeking a Certified Professional Coder (CPC) to perform medical claim reviews for the SIU. The role requires determining correct coding and documentation, ensuring compliance with state, federal, and company requirements, and recognizing billing concerns through comprehensive record reviews.

Qualifications include AAPC CPC certification and 3+ years of coding/medical record review experience, with proficiency in CPT/HCPCS and CMS guidelines. Travel may be needed.

Qualifications

• Minimum 3 years of medical and/or behavioral health coding experience, with 1–2 years of current professional coding and medical record review.
• Knowledge of CPT, HCPCS, and Revenue Codes and familiarity with CMS 1500 and UB04 data elements.
• Ability to interpret and apply coding policies and guidelines consistently.
• Proficiency with Microsoft Excel and Word.
• Willingness to travel for the role if needed.

Responsibilities

• Conduct comprehensive medical record reviews to ensure CPT/HCPCS/revenue codes and modifiers align with documentation.
• Provide detailed written summaries of review findings.
• Explain findings to investigators, plan leadership, law enforcement, legal counsel, providers and regulators.
• Research and apply state or CMS guidelines related to reviews with minimal support.
• Review cases with Medical Directors to validate decisions.
• Identify potential billing errors, abuse and fraud and opportunities for savings.
• Maintain records and documentation; follow workflows to meet metrics.
• Stay up-to-date with coding changes and reimbursement guidelines.

Skills

CPC Certification

Medical coding

Medical record review

CPT/HCPCS knowledge

CMS guidelines

Excel

Travel willingness

Education

CPC Certification

GED/High School Diploma

Tools

Excel

Word

Job description

CVS Health is seeking a Certified Professional Coder (CPC) to perform medical claim reviews for the SIU. The role requires determining correct coding and documentation, ensuring compliance with state, federal, and company requirements, and recognizing billing concerns through comprehensive record reviews.

Qualifications include AAPC CPC certification and 3+ years of coding/medical record review experience, with proficiency in CPT/HCPCS and CMS guidelines. Travel may be needed.