CPC SIU Medical & Behavioral Health Auditor

Pennsylvania Psychological Association; Columbus (OH); On-site; USD 56,000 - 94,000; 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 CPC will determine correct coding and documentation during medical record reviews while ensuring compliance with state, federal, and company requirements.

Responsibilities include reviewing CPT/HCPCS/Revenue codes, providing written summaries, and communicating findings to investigators, leadership, providers, and regulators.

Qualifications

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

Responsibilities

• Conduct comprehensive medical record reviews to verify CPT/HCPCS/Revenue codes align with documentation.
• Provide detailed written summaries of findings.
• Articulate findings to investigators, leadership, providers, regulators and others.
• Apply state and CMS guidelines to coding reviews with minimal supervision.
• Discuss cases with Medical Directors to validate decisions.
• Assist with investigations related to coding questions and fraud detection.
• Identify billing errors, abuse and potential savings opportunities.
• Maintain records and follow workflows to meet metrics.
• Stay updated on coding changes and reimbursement guidelines.

Skills

CPC coding

Medical record review

Policy interpretation

MS Excel

MS Word

Travel readiness

Education

AAPC CPC certification

GED or High School diploma

Tools

Microsoft Excel

Microsoft Word

Job description

CVS Health is seeking a Certified Professional Coder (CPC) to perform medical claim reviews for the Special Investigations Unit (SIU). The CPC will determine correct coding and documentation during medical record reviews while ensuring compliance with state, federal, and company requirements.

Responsibilities include reviewing CPT/HCPCS/Revenue codes, providing written summaries, and communicating findings to investigators, leadership, providers, and regulators.