Healthcare Audit & Compliance Specialist (Claims & Coding)

NACBA; South Carolina; On-site; USD 47,000 - 122,000; Full time

Job summary

CVS Health is seeking a Program Integrity Auditor to review provider medical records and ensure proper coding and documentation across multiple lines of business. The role includes identifying aberrant billing patterns, recommending follow-up actions, and educating providers on regulatory requirements.

This full-time position requires 3–5 years of claims and medical record review, coding expertise (CPT/HCPCS/ ICD-10), and an active CPC/CCS/CPMA credential.

Qualifications

• 3–5 years of experience reviewing and interpreting claims data and medical records.
• 3–5 years experience with CPT, HCPCS, and ICD-10 coding guidelines.
• Active CPC, CCS, or CPMA license required.

Responsibilities

• Audit records for Medicaid health plans across multiple lines of business for coding accuracy.
• Review provider records to ensure correct coding, modifiers, and place of service.
• Coordinate audit documentation and reports for internal and external stakeholders.
• Identify aberrant billing patterns and potential FWA; assist regulators as needed.
• Support development of FWA avoidance, detection and referral plans.

Skills

Claims data review

Medical records interpretation

Coding knowledge CPT/HCPCS/ICD-10

AZ time zone availability

Education

Associate's degree or equivalent experience

Tools

QuickBase

Job description

CVS Health is seeking a Program Integrity Auditor to review provider medical records and ensure proper coding and documentation across multiple lines of business. The role includes identifying aberrant billing patterns, recommending follow-up actions, and educating providers on regulatory requirements.

This full-time position requires 3–5 years of claims and medical record review, coding expertise (CPT/HCPCS/ ICD-10), and an active CPC/CCS/CPMA credential.