CPC Medical Coding & SIU Audit Analyst

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

Job summary

CVS Health is seeking a Certified Professional Coder (CPC) for the Special Investigations Unit to review medical records for compliant coding and documentation. You will determine correct CPT/HCPCS usage and ensure state and federal requirements are met, while identifying potential fraud and savings opportunities.

The role requires 3+ years of medical/behavioral health coding, CPC certification, and proficiency with CPT/HCPCS/Revenue Codes.

Qualifications

• AAPC CPC certification is required.
• Minimum of 3 years of medical/behavioral health coding experience, with 1–2 years of medical record review.
• Knowledge of CPT, HCPCS, Revenue Codes, CMS 1500 and UB04 data elements.
• Ability to interpret and apply coding policies and guidelines consistently.
• Proficiency with Microsoft Excel and Word; ability to travel if needed.

Responsibilities

• Conduct comprehensive medical record reviews to ensure codes and modifiers align with documentation.
• Provide detailed written summaries of findings from reviews.
• Articulate findings to investigators, leadership, and regulators as needed.
• Research and apply CMS/state guidelines related to reviews.
• Discuss cases with Medical Directors to validate decisions.
• Identify billing errors, potential fraud, and opportunities for savings.
• Maintain records and follow workflows to meet performance metrics.
• Keep coding knowledge up to date with changes in compliance and reimbursement.

Skills

Medical coding expertise

Documentation auditing

Interpret coding policies

Communication skills

Education

AAPC CPC Certification

GED or High School diploma

Tools

Excel

Word

Job description

CVS Health is seeking a Certified Professional Coder (CPC) for the Special Investigations Unit to review medical records for compliant coding and documentation. You will determine correct CPT/HCPCS usage and ensure state and federal requirements are met, while identifying potential fraud and savings opportunities.

The role requires 3+ years of medical/behavioral health coding, CPC certification, and proficiency with CPT/HCPCS/Revenue Codes.