Health Plan Integrity Auditor — Compliance & FWA Expert

NACBA; Nevada (IA); Hybrid; USD 47,000 - 122,000; Full time

Job summary

CVS Health is seeking a Program Integrity Auditor to review medical, behavioral, transportation, and other provider records. The Auditor will determine correct coding and documentation and may recommend follow‑ups, recoupment, rebilling, or regulator referrals.

The role requires CPC/CCS/CPMA certification, 3–5 years of claims data experience, and availability Monday–Friday 8am–5pm Arizona Time. This full‑time position offers competitive pay and comprehensive benefits.

Qualifications

• 3-5 years of experience in reviewing and interpreting claims data, as well as medical records and appropriate documentation.
• 3-5 years of experience with standard industry coding guidelines such as CPT, HCPCS, and ICD-10.
• Willingness to work Monday-Friday from 8am-5pm Arizona Time Zone.
• Must possess an active CPC, CCS, or CPMA license.

Responsibilities

• Audit records on a routine basis, as well as records for audits for all lines of business, in order to ensure coding and documentation meet regulatory standards.
• Coordinate audit documentation and reports for review for internal and external staff and stakeholders.
• Identify aberrant billing patterns and potential FWA, reporting this to internal staff. Assisting with further investigation and/or reports to state regulators through the utilization of developed critical thinking skills.
• Assist with the development and implementation plan for prospective and retrospective FWA avoidance, detection, and referral.
• Assist with the creation and submission of regulator deliverables through completion of timely audit activities.
• Provide technical assistance and education to providers including training on regulatory requirements, as well as coding and documentation rules.
• Maintain compliance with company policies and procedures.
• Perform other duties as assigned.

Skills

Claims data review

Medical records interpretation

CPT/HCPCS/ICD-10 coding

Regulatory compliance

Audit coordination

Critical thinking

Training and education

Education

Associate degree or equivalent

Tools

QuickBase

Job description

CVS Health is seeking a Program Integrity Auditor to review medical, behavioral, transportation, and other provider records. The Auditor will determine correct coding and documentation and may recommend follow‑ups, recoupment, rebilling, or regulator referrals.

The role requires CPC/CCS/CPMA certification, 3–5 years of claims data experience, and availability Monday–Friday 8am–5pm Arizona Time. This full‑time position offers competitive pay and comprehensive benefits.