Medical & Behavioral Health Coding & Compliance Analyst

Istss; Richmond (VA); Hybrid; USD 44.000 - 94.000; Vollzeit

Zusammenfassung

CVS Health in Richmond, VA is seeking a Certified Professional Coder (CPC) to perform medical claim reviews for the Special Investigations Unit (SIU). You will ensure CPT/HCPCS codes and modifiers align with documentation and that state, federal, and company rules are followed.

The role includes reporting findings, discussing cases with Medical Directors, identifying billing errors and fraud indicators, and maintaining complete records.

Qualifikationen

• AAPC CPC certification is required.
• Minimum of 3 years of medical and/or behavioral health coding experience including medical record review and documentation auditing.
• Knowledge of CPT, HCPCS and Revenue Codes.
• CMS 1500 and UB04 data elements.
• Ability to apply coding policies and guidelines.

Aufgaben

• Conduct comprehensive medical record reviews to verify CPT/HCPCS/revenue codes align with documentation.
• Provide detailed written summaries of review findings.
• Articulate findings to investigators, plan leadership, law enforcement, and regulators.
• Research state or CMS guidelines related to reviews with minimal support.
• Review cases with Medical Directors to validate decisions.
• Assist with investigative coding research and identify billing errors, abuse or fraud.
• Identify savings opportunities warranting prepayment review.
• Maintain records and follow workflows to meet metrics.

Kenntnisse

CPC certification knowledge

Medical coding experience

Interpret coding guidelines

Attention to detail

Communication skills

Travel readiness

Ausbildung

AAPC CPC certification

GED or High School diploma

Tools

Microsoft Excel

Microsoft Word

Jobbeschreibung

CVS Health in Richmond, VA is seeking a Certified Professional Coder (CPC) to perform medical claim reviews for the Special Investigations Unit (SIU). You will ensure CPT/HCPCS codes and modifiers align with documentation and that state, federal, and company rules are followed.

The role includes reporting findings, discussing cases with Medical Directors, identifying billing errors and fraud indicators, and maintaining complete records.