Medical Coding Auditor - Compliance & Fraud Prevention

Hispanic Alliance for Career Enhancement; Minnesota; Hybrid; USD 43,888 - 93,574; Full time

Job summary

CVS Health is seeking a Certified Professional Coder (CPC) to perform medical claim reviews for the SIU, ensuring coding accuracy and compliant documentation. The role requires 3+ years of experience and CPC certification, with strong knowledge of CPT/HCPCS/ICD-10 and CMS guidelines.

The candidate will conduct audits, provide written findings, and communicate results to investigators and regulators. Proficiency in Excel/Word and attention to detail are essential for success in this full-time

Qualifications

• AAPC CPC certification required.
• 3+ years of experience in medical coding or documentation auditing.
• Knowledge of CPT, HCPCS, ICD-10, CMS 1500 and UB04 data elements.
• Experience with researching coding and policies.
• Proficient in Microsoft Excel and Word.

Responsibilities

• Conduct a comprehensive medical record audit to ensure CPT/HCPCS or modifiers billed are consistent with medical record documentation.
• Provide detailed written summary of medical record review findings.
• Articulate findings to investigators, Medicaid plan leadership, law enforcement, legal counsel, providers, state regulators, etc.
• Research and accurately apply state or CMS guidelines related to the audit with minimal support.
• Review and discuss cases with Medical Directors to validate decisions.
• Assist with investigative research related to coding questions, state and federal policies.
• Identify potential billing errors, abuse, and fraud.
• Identify opportunities for savings related to potential cases which may warrant a prepayment review.
• Maintain appropriate records, files, documentation, etc.
• Maintains up-to-date coding knowledge, including new changes to coding compliance and reimbursement.

Skills

CPC Certification

Medical Coding

CPT/HCPCS/ICD-10

Excel

Word

Education

GED or equivalent

AAPC CPC Certification

Tools

Microsoft Excel

Microsoft Word

Job description

CVS Health is seeking a Certified Professional Coder (CPC) to perform medical claim reviews for the SIU, ensuring coding accuracy and compliant documentation. The role requires 3+ years of experience and CPC certification, with strong knowledge of CPT/HCPCS/ICD-10 and CMS guidelines.

The candidate will conduct audits, provide written findings, and communicate results to investigators and regulators. Proficiency in Excel/Word and attention to detail are essential for success in this full-time