Healthcare Program Integrity Auditor

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

Benefits offered by this job

Medical, dental, and vision coverage

Comprehensive benefits package

Paid time off

Job summary

CVS Health is seeking a Program Integrity Auditor to review medical and behavioral records, ensuring accurate coding and compliant documentation. The role involves audits across Medicaid lines of business, education for providers, and reporting potential fraud, waste, or abuse to regulators.

The auditor will work to identify coding inconsistencies, coordinate audit reports, and support prospective and retrospective FWA avoidance initiatives. A CPC/CCS/CPMA license is required.

Qualifications

• 3-5 years of reviewing and interpreting claims data and medical records.

Responsibilities

• Audit records for Medicaid lines of business to ensure coding accuracy.
• Review provider records for regulatory compliance and documentation standards.
• Coordinate audit documentation and prepare reports for internal/external stakeholders.
• Identify aberrant billing patterns and potential FWA.
• Assist with FWA avoidance, detection, and referral plans.
• Contribute to regulator deliverables via timely audit work.
• Provide training on regulatory requirements and coding rules to providers.
• Maintain compliance with company policies and procedures.
• Perform other duties as assigned.

Skills

Claims data review

Medical records review

Coding guidelines CPT/HCPCS/ICD-10

Active CPC/CCS/CPMA license

Arizona time availability

Education

Associate degree or equivalent experience

Tools

QuickBase

Job description

CVS Health is seeking a Program Integrity Auditor to review medical and behavioral records, ensuring accurate coding and compliant documentation. The role involves audits across Medicaid lines of business, education for providers, and reporting potential fraud, waste, or abuse to regulators.

The auditor will work to identify coding inconsistencies, coordinate audit reports, and support prospective and retrospective FWA avoidance initiatives. A CPC/CCS/CPMA license is required.