CPC SIU Medical & Behavioral Health Auditor

Pennsylvania Psychological Association; Madison (WI); 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 Special Investigations Unit (SIU), ensuring coding accuracy across medical, behavioral health, transportation, and other services. The CPC determines correct coding and documentation during record reviews and ensures compliance with state, federal, and company requirements.

Responsibilities include comprehensive case reviews, detailed findings, and communication with investigators and regulators.

Qualifications

• AAPC CPC certification required.
• Minimum of 3 years of medical and/or behavioral health coding experience, with at least 1-2 years of current professional 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 and guidelines.

Responsibilities

• Conduct comprehensive medical record reviews to ensure CPT/HCPCS/revenue codes match documentation.
• Provide detailed written summaries of review findings.
• Articulate findings to investigators, leadership, and regulators.
• Research 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.
• Maintain records and follow workflows to meet metrics.
• Stay up-to-date on coding compliance and reimbursement changes.

Skills

Medical coding

Written communication

Verbal communication

Education

GED or High School diploma

AAPC 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), ensuring coding accuracy across medical, behavioral health, transportation, and other services. The CPC determines correct coding and documentation during record reviews and ensures compliance with state, federal, and company requirements.

Responsibilities include comprehensive case reviews, detailed findings, and communication with investigators and regulators.