Healthcare Program Integrity Auditor

NACBA; Tennessee; Hybrid; USD 47,000 - 122,000; Full time

Benefits offered by this job

Medical, dental, vision coverage

Retirement savings options

Paid time off

Job summary

CVS Health is seeking a Program Integrity Auditor to review medical, behavioral, transportation, and other provider records to ensure accurate coding and documentation. The role includes identifying improper billing patterns and advising on follow-up actions, including education, recoupment, or regulator referrals.

The position requires 3–5 years in claims data and medical record review, CPT/HCPCS/ICD-10 expertise, and an active CPC/CCS/CPMA certification.

Qualifications

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

Responsibilities

• Audit records for multiple lines of business to ensure regulatory coding and documentation.
• Coordinate audit documentation and reports for internal/external staff and stakeholders.
• Identify aberrant billing patterns and potential FWA; assist with investigations and regulator reporting.
• Provide education on regulatory requirements, coding and documentation rules to providers.
• Maintain compliance with company policies and procedures.

Skills

Claims data review

Medical records review

Coding guidelines

Education

Associate's degree or equivalent

Tools

QuickBase

Job description

CVS Health is seeking a Program Integrity Auditor to review medical, behavioral, transportation, and other provider records to ensure accurate coding and documentation. The role includes identifying improper billing patterns and advising on follow-up actions, including education, recoupment, or regulator referrals.

The position requires 3–5 years in claims data and medical record review, CPT/HCPCS/ICD-10 expertise, and an active CPC/CCS/CPMA certification.